Presented  by 
Mrs.   G.  W.  Haas 


COLLEGE  OF  OSTEOPATHIC   PHYSICIANS 
AND  SURGEONS  •  LOS  ANGELES,  CALIFORNIA 


TUBERCULOSIS 


LJ 


OF 


BONES  AND  JOINTS: 


BY 


N.  SENN,  M.D.,  PH.D., 

CHICAGO,  ILL. 


PROFESSOR  Or  PRACTICE  OF  SURGERY  AND  CLINICAL  SURGERY  IN   RUSH  MBDICAL  COLLEGE ;     PROFESSOR  Or  SURGERY 
IN    THE    CHICAGO    POLYCLINIC ;     ATTENDING    SURGEON     PRESBYTERIAN    HOSPITAL;     SURGEON-IN-CHIEF    ST. 

JOSEPH'S  HOSPITAL;    PRESIDENT  or  THE   AMERICAN   SURGICAL  ASSOCIATION;    PRESIDENT  or 

THE  ASSOCIATION     OF    MILITARY   SURGEONS  OF  THE   NATIONAL    GUARD  OF  THE    UNITED 

STATES;    PERMANENT  MEMBER  or  THE  GERMAN  CONGRESS  or  SURGEONS,  ETC. 


PHILADELPHIA   AND  LONDON  : 

THE  F.  A.  DAVIS  CO.,  PUBLISHERS. 

1892. 


U)t~ 


Entered  according  to  Act  of  Congress,  in  the  year  1892,  by 

THE  F.  A.  DAVIS  COMPANY, 

In  th«  Office  of  the  Librarian  of  Congress,  at  Washington,  D.  C.,  U.  S.  A. 
All  rights  reserved. 


Philadelphia,  Pa.,  U.  8.  A.: 

The  Medical  Bulletin  Printing  II«nae. 

1916  Cherry  Street. 


THE  AUTHOR 

TAKES  GREAT  PLEASURE  IN  DEDICATING  THIS  VOLUME 

TO   HIS  FRIENDS, 

THE  FELLOWS  OF  THE  AMERICAN  SURGICAL 
ASSOCIATION, 

WHO     HAVE     CONTRIBUTED     SO    MUCH     TOWARD     THE 

ADVANCEMENT    OF   SURGERY    IS   THE 

UNITED  STATES. 


F 


PREFACE. 


TUBERCULOSIS  of  bones  and  joints  is  such  a  common  affection 
that  a  large  percentage  of  the  clinical  material  of  the  surgeon 
and  the  general  practitioner  is  made  up  of  such  cases.  The 
tubercular  nature  of  most  of  the  chronic  affections  of  bones  and 
joints  is  not  as  freely  accepted  and  as  fully  realized  as  it  should 
be  by  the  mass  of  the  profession,  and  consequently  a  correct 
diagnosis  is  often  not  made  before  the  disease  has  become  in- 
curable. The  successful  treatment  of  these  affections  depends 
largely  on  an  early,  correct  diagnosis  and  the  adoption  of  a 
timely,  rational,  local,  and  general  treatment  in  consonance  with 
the  true  nature  of  the  disease.  The  object  of  the  author  in 
writing  this  book  has  been  to  collect  from  recent  literature  the 
modern  ideas  on  tubercular  disease  of  bones  and  joints  and 
present  them  to  the  reader  in  a  condensed  form,  mingled,  in 
appropriate  places,  with  the  results  of  his  own  experience.  Old 
authorities  are  occasionally  quoted  for  the  purpose  of  showing 
the  contrast  between  the  old  and  recent  views  regarding  the 
etiology  and  nature  of  this  form  of  bone  and  joint  disease.  My 
thanks  are  due  to  Dr.  Stehman  for  correcting  the  galley-proofs, 
and  to  Mr.  Rettig  for  a  number  of  original  drawings.  If  this 
work  should  become  useful  in  alleviating  one  of  the  most  com- 
mon ailments  of"  the  poor,  and  add  something  toward  the 
advancement  of  the  surgery  of  the  bones  and  joints,  the  hope 
and  ambition  of  its  author  will  be  realized. 

N.  SENN. 

CHICAGO,  September  1,  1892. 


TABLE  OF  CONTENTS. 


PAGE 

PREFACE, v 

TABLE  OF  CONTENTS, vii 

LIST  OF  ILLUSTRATIONS, xi 

CHAPTER  I. 
HISTORY, 1 

CHAPTER  II. 

PROOFS  WHICH   ESTABLISH  THE   TUBERCULAR   NATURE  OF  THE   SO- 
CALLED  STRUMOUS  DISEASE  OF  BONES  AND  JOINTS,       .        .        7 

CHAPTER  III. 
BACILLUS  TUBERCULOSIS,    .        .        . 22 

CHAPTER  IV. 
HISTOLOGY  OF  TUBERCLE,  .        . 27 

CHAPTER  Y. 

HlSTOQENESIS   OF   TUBERCLE, 41 

CHAPTER  VI. 
CASSATION, 46 

CHAPTER  VII. 
TUBERCULAR  ABSCESS, .        .49 

CHAPTER  VIII. 

TOPOGRAPHY  OF  BONE  AND  JOINT  TUBERCULOSIS,      ....      65 

(vii) 


viii  TABLE  OF  CONTENTS. 

CHAPTER  IX. 

PAGE 

BONE  TUBERCULOSIS, 69 

CHAPTER  X. 
ETIOLOGY  OF  BONE  TUBERCULOSIS, 91 

CHAPTER  XI. 

SYMPTOMS  AND  DIAGNOSIS  OF   TUBERCULAR  BONE  AFFECTIONS,        .       97 

CHAPTER  XII. 
PROGNOSIS  OF  TUBERCULAR  DISEASE  OF  BONE, Ill 

CHAPTER  XIII. 
TREATMENT  OF  TUBERCULOSIS  OF  BONE, 116 

CHAPTER  XIV. 
TUBERCULOSIS  OF  JOINTS, 127 

CHAPTER  XT. 

SPECIAL  POINTS  IN  THE  PATHOLOGY  OF  SYNOVIAL  TUBERCULOSIS,    .     145 

CHAPTER  XVI. 
ETIOLOGY, 157 

CHAPTER  XVII. 

SYMPTOMS  AND  DIAGNOSIS, 166 

CHAPTER  XVIII. 

PROGNOSIS,          ...  ...     180 

CHAPTER  XIX. 
TREATMENT  OF  TUBERCULOSIS  OF  JOINTS, 185 

CHAPTER  XX. 
LOCAL  TREATMENT, 192 


TABLE   OF    CONTENTS.  IX 

CHAPTER  XXI. 

PAGE 

LOCAL  TREATMENT  (continued), *  205 

CHAPTER  XXII. 
TUBERCULIN  TREATMENT, .        .        .215 

CHAPTER  XXIII. 

TREATMENT  OF  TUBERCULOSIS  OF  JOINTS  BY  PARENCHYMATOUS  AND 

I NTR A.- ARTICULAR.  INJECTIONS, 238 

CHAPTER  XXIV. 

TREATMENT  OF  TUBERCULOSIS  OF   JOINTS  BY  PARENCHYMATOUS  AND 

INTRA-ARTICULAR  INJECTIONS  (continued),  •   .         .        .         .     255 

CHAPTER  XXV. 
OPERATIVE  TREATMENT, 281 

CHAPTER  XXVI. 
RESECTION, 292 

CHAPTER  XXVII. 
ATYPICAL  AND  TYPICAL  RESECTION, 306 

CHAPTER  XXVIII. 
IMMEDIATE  AND  REMOTE  RESULTS  OF  RESECTION,    ....     316 

CHAPTER  XXIX. 
AMPUTATION, 332 

CHAPTER  XXX. 

POST-OPERATIVE    TREATMENT,      .  .  .  .  .  .  .  337 

CHAPTER  XXXI. 
TUBERCULOSIS  OF  SPECIAL  BONES, 340 


X  TABLE   OF   CONTENTS. 

CHAPTER  XXXII. 

PAGE 

TUBERCULOSIS  OF  THE  BONES  OF  THE  TRUNK, 353 

• 

CHAPTER  XXXIII. 

TUBERCULOSIS  OF  PELVIC  BONES,  SCAPULA,  CLAVICLE,  STERNUM,  AND 

RIBS, 385 

CHAPTER  XXXIV. 
TUBERCULOSIS  OF  JOINTS  OF  UPPER  EXTREMITY,      ....    397 

CHAPTER  XXXV. 

TUBERCULOSIS  OF  HIP-JOINT, 428 

CHAPTER  XXXVI. 
TUBERCULOSIS  OF  KNEE-JOINT, 452 

CHAPTER  XXXVII. 
TUBERCULOSIS  OF  ANKLE-JOINT  AND  TARSUS, 473 

INDEX, 497 


LIST  OF   ILLUSTRATIONS. 


FIG.  PAGE 

xl.  (Plate  I.)    Tubercle  bacilli  containing  spores  (R.  Koch), 22 

2.  (Plate  I.)     Tubercle  bacilli  from  a  tubercular  cavity,   .        .        .   '     .        .        .23 

3.  (Plate  II.)     Vegetations  of  tubercle  bacilli  (Baumgarten), 24 

4.  (Plate  III.)     Colony  of  tubercle  bacilli  (Frankel  and  Pfeifler),    ....      24 

5.  (Plate  IV.)      Preparation    from  tissue-juice  of   inoculation   tubercle  (Baum- 

garten),          25 

6.  (Plate  IV.)     Giant-cell  with  radiating  arrangement  of  bacilli  (Koch),        .        .  25 

7.  Primary  tubercle, 30 

8.  Giant-cell  from  centre  of  tubercle  of  lung  (Hamilton), 31 

9.  A  giant-cell  from  the  lung  in  a  case  of  chronic   phthisis,  showing  the  large 

number  of  nuclei  with  eight  nucleoli  (Green),          .        .        .        .        .        .32 

10.  Multinucleated  and  branched  cells  from  a  fine,  gray,  miliary  tubercle  of  the  lung, 

in  a  case  of  acute  tuberculosis  (Green), 35 

11.  Fully-developed  reticular  tubercle  of  lung  (Hamilton), 36 

12.  (Plate  V.)     Circumscribed  tubercle  of  iris  (Baumgarten), 37 

13.  Miliary  tubercle  in  the  pia  mater  (Cornil  and  Ranvier), 42 

14.  Abscess-membrane  from  a  tubercular  abscess  (Volkinann),   .....  56 

15.  Typical  granulation  tuberculosis  of  bone  with  many  round  and  oblong  tubercles 

and  with  stripes  of  tubercular  tissue, — tubercle  tissue  (Konig),      ...      74 

16.  Upper  portion  of  femur  of  boy  six  years  old  who  died  of  general  tuberculosis 

(Krause), 76 

17.  Lower  articular  extremity  of  femur  with  cheesy  focus,  which  at  a  has  reached 

the  surface  outside  the  insertion  of  the  synovial  membrane.    Joint  not  affected 
(Konig), 79 

18.  Wedge-shaped  tubercular  sequestrum  in  the  head  of  the  tibia.     Bone  and  seques- 

trum   divided    longitudinally.      Base  of   sequestrum    extending  into  joint 
(Konig), 81 

19.  Resected  upper  end  of  femur  from  a  girl  five  years  old  (Krause),          ...      82 

20.  Fistula  over  middle  of  trochanter  major,  leading  into  the  neck  of  the  femur,  in  a 

girl  twelve  years  old  (Volkmann), 123 

21.  Common  form  of  osteotuberculosis  of  elbow-joint  (Volkmaun),    ....    130 

22.  Typical  granulation  tuberculosis  of  synovial  membrane  with  many  round  and 

oblong  tubercles,  and  between  them  stripes  of  tubercular  infiltration  (Konig),     131 

23.  Secondary  tuberculosis  of  knee-joiut.     Great  hypertrophy  of  synovial  and  sub- 

synovial  tissues.     Half  natural  size  (Krause),  .        ......  r140" 

24.  Secondary  tuberculosis  of  knee-joiut.     Great  hypertrophy  of  synovial  and  sub- 

synovial  tissues.     Natural  size  (Krause), 140 

25.  Secondary  tuberculosis  or  knee-joint.     Great  hypertrophy  of  synovial  and  sub- 

synovial  tissues.     Natural  size  (Krause), 140 

26.  Resected  upper  end  of  femur  (Volkmann), 143 

27.  Extirpated  piece  of  capsule  of  knee-joint,  showing  numerous  papillomatous  pro- 

jections (Konig), 146 

28.  Primary  osseous  tuberculosis  of  head  of  femur  (Krause), 151 

29.  Early  stage  of  coxitis — slight  flexion  of  thigh  and  rotation  of  limb  outward 

(Sayre), 171 

(Xi) 


Xll  LIST   OF   ILLUSTRATIONS. 

FIG.  PAGE 

30.  Typical  appearance  of  knee-joint,  caused  by  long-standing  tubercular  disease  of 

the  joint  (Sayre), 171 

31.  (Plate  VI.)    Acromegalia  (?).     Osteitis  deformans  (Marie),         ....  177 

32.  Permanent  extension  by  weight  and  pulley  in  three  directions  in  disease  of  the 

knee-joint  which  was  caused  by  flexion  and  subluxation  of  the  tibia  back- 
ward (Krause), 202 

33.  Koch's  syringe,          . 215 

34.  (Plate  VII.)     Bacilli  before  injection  (Koch), 217 

35.  (Plate  VII.)     Bacilli  after  injection  (Koch), 217 

36.  Partial  arthrectomy  of  knee-joint  (Medical  News), 285 

37.  Atypical  resection  of  knee-joint,  with  splicing  of  articular  ends,  ....  308 

38.  Konig's  operation  of  resection  of  the  hip-joint, 311 

39.  Baker's  pins  to  hold  bone  surfaces  in  apposition  (British  Medical  Journal),  .        .  315 

40.  Tuberculosis  of  cranial  bones.     Inner  surface  of  cranial  vault  after  separation  of 

durajnater  and  brain,  which  are  pushed  toward  the  left  (Krause),         .        .  342 

41.  Lower  dorsal  and  lumbar  portion  of  spinal  column  of  child  (Krause),          .        .  356 

42.  Tubercular  spondylitis  of  lower  dorsal  vertebrae  (Krause), 358 

43.  Same  specimen,  vertical  section  (Krause), 359 

44.  Vertical  section  through  spinal  column  (Krause), 363 

45.  Extensive  tubercular  destruction  of  the  bodies  of  a  number  of  adjoining  dorsal 

vertebrae,   causing  a   long   posterior  curve  instead  of  an   angular  gibbus 

(Krause), 363 

46.  Sharp  angular  curvature  of  spine,  caused  by  extensive  destruction  of  the  ninth 

dorsal  vertebra,  of  which  only  a  small  triangular  piece  remains  at  a;  at  this 

point  a  fistulous  opening  leads  into  a  psoas  abscess  (Krause),          .        .        .  364 

47.  Spondylitis  of  middle  dorsal  vertebrae.     Rauchfuss's  apparatus  combined  with 

head-extension  by  Glisson's  swing  (Krause), 372 

48.  Caries  of  lower  lumbar  vertebrae.      Rauchfuss's  apparatus  with  extension  on 

both  legs  (Krause), 373 

49.  Sayre's  suspension  apparatus, 374 

50.  Child  suspended  and  ready  for  application  of  plaster-of-Paris  bandage,        .        .  375 

51.  Spondylitis  of  upper  dorsal  vertebrae.     Sayre's  plaster-of-Paris  jacket,  with  jury- 

mast.     Volkmann's  walking-stool  (Krause), 375 

52.  Sacro-iliac  disease.     Rope  of  oakum  passed  through  sinus  whole  length  of  joint 

(Sayre), 386 

53.  Same  case.     Sinuses  in  perineum  drained  in  same  manner  (Sayre),      .        .        .  387 

54.  Caries  sicca  of  Bhoulder-joint  (Volkmann), 398 

55.  Resection  of  shoulder-joint,  straight  anterior  incision, 403 

56.  Excision   of  shoulder-joint  and  upper  third  of  humerus.     Result  twenty-five 

years  after  operation  (Annals  of  Surgery),          .......  405 

57.  Tuberculosis  of  the  elbow-joint,  with  marked  atrophy  of  muscle  of  arm  and 

forearm, 407 

58.«  Langenbec"k's  incision  (Bryant) , 410 

59.  Listen's  incision  (Bryant), 410 

60.  Bracketed  double  splint  (Esmarch),        . 414 

61.  Wooden  splint  with  opening  for  internal  condyle  (Stromeyer),               '.  414 

62.  Curved  wooden  splint,      .............  415 

63.  Wire  splint  incased  by  plaster-of-Paris  bandage, 416 

64.  Langenbeck's  incision, .        .        .        .  419 

65.  Lister's  double  incision, 420 

66.  Coxltis,  left  side, 431 

67.  Coxitis,  left  side,  second  stage, 431 

68.  Third  stage  of  coxitis, .  432 


LIST   OF   ILLUSTRATIONS.  Xlll 

FIG.  PAGE 

69.  Third  stage  of  coxitis, 432 

70.  Position  of  limb  in  dorsal  recumbent  position  of  patient  during  the  early  stage 

of  coxitis, 433 

71.  Tilting  of  pelvis  and  curving  of  spine  when  affected  limb  is  brought  down  even 

with  the  limb  on  the  opposite  side, 433 

72.  Extension  by  weight  and  pulley, 435 

73.  Thomas'  splint  arranged  for  walking,  with  crutches  and  patten  under  foot  on 

sound  side, 436 

74.  Double  Thomas' splint,     . .        .436 

75.  Sayre's  long  hip-splint, 437 

76.  Volkmann's  splint  applied,      ............  437 

77.  White's  posterior  curved  incision, 444 

78.  Langenbeck's  longitudinal  incision,        .        .        . 444 

79.  Sayre's  line  of  incision, 445 

80.  M.  J.  Robert's  operation  of  excision  of  the  hip-joint, 445 

81.  Resection  of  hip-joint  four  months  after  operation  (Harwell),        ....  449 

82.  Resection  of  hip-joint  twelve  years  after  operation  (Harwell),       ....  449 

83.  Resection  of  acetabulum.     Sections  through  bone, 450 

84.  Tubercular  synovitis  of  the  knee-joint,  with  effusion, 452 

85.  Tubercular  osteomyelitis  of  internal  condyle  of  femur, 453 

86.  Tubercular  osteomyelitis  of  both  condyles  of  femur, 453 

87.  Caries  necrotica  of  tibia  (diastasis),        .        .        . 454 

88.  Anterior  curved  incision.     Convexity  of  flap  directed  upward,      .        .        .        .  456 

89.  Ollier's  incision,        .        .        .- .        .  458 

90.  Mackenzie's  anterior  curved  incision, 458 

91.  Drill  and  bone-nails  for  direct  fixation  of  fragments  after  resection  of  the  knee- 

joint  (Bryant) , 461 

92.  Epiphysial  cartilage  and  line  of  section  in  excision  of  the  knee-joint  (Bryant),  .  462 

93.  Gluck's  ivory  joint, 463 

94.  Shortening  of  limb  after  complete  resection  of  the  knee-joint,  with  removal  of 

both  epiphysial  cartilages  (Pemberton's  case), 466 

95.  Sagittal  section  of  os  calcis  (Krause), 473 

96.  Tubercular  osteomyelitis  of  astragalus, 474 

97.  Fungous  synovitis  of  ankle-joint, 474 

98.  Heuter's  anterior  incision, 476 

99.  Konig's  incisions, 478 

100.  Lauenstein's  operation.     External  incision, 483 

101.  Lauenstein's  operation.     Deep  dissection, 484 

102.  Girard's  method  of  excision  of  the  ankle-joint, 487 

103.  Excision  of  ankle-joint  in  child  several  months  after  operation,     ....  489 

104.  Excision  of  the  os  calcis, 490 

105.  Mikulicz-WladimirofPs  osteoplastic  resection  of  the  tarsus.     Incision  through 

soft  parts, 490 

106.  Bone  sections, 491 

107.  Position  of  foot  and  toes  after  this  operation, .,,,....  491 


TUBERCULOSIS  OF  BONES  AND  JOINTS. 


CHAPTER  I. 

HISTORY. 

THE  history  of  tubercular  affections  of  bones  and  joints  is 
quite  an  interesting  one,  as  the  early  part  of  it  gives  an  account 
of  the  crudest  ideas  in  reference  to  the  etiology,  pathology,  and 
treatment  of  these  affections ;  while  that  part  which  covers  the 
last  decade  bristles  with  new  revelations  and  startling  discov- 
eries, based  on  accurate  clinical  observation,  microscopical 
examination,  bacteriological  investigation,  and  experimental 
research.  No  department  in  medicine  or  surgery  has  witnessed 
a  more  radical  change  than  the  etiology  of  tuberculosis  of  bones 
and  joints.  During  the  time  of  Hippocrates  some  general 
facts  were  understood,  such  as  that  phthisis  develops  more  or 
less  directly  after  certain  surgical  accidents  or  diseases ;  but 
nothing  definite  was  known.  Less  than  a  century  ago,  we  find 
chronic  inflammatory  affections  of  bone  designated  by  such 
vague  terms  as  spina  ventosa,  osteoplitlioria,  osteospongiosis 
(Lobstein),  and  pcedartJirocace  (Severin).  J.  L.  Petit  did  not 
know  under  what  head  he  should  classify  these  affections.  He 
was  in  serious  doubt  whether  they  should  be  classified  with 
exostosis,  softening  of  bone,  caries,  atrophy,  necrosis,  or  whether 
they  formed  a  separate  group  of  bone-lesions,  which  should  be 
brought  under  a  distinct  head.  Tuberculosis  of  bone,  as  we 
now  understand  it,  was  described  by  Boerhave  as  a  destructive 
process  in  the  epiphyses,  extending  from  within  outward.  A. 
G.  Richter,  Bottcher,  and  Hebenstreit  regarded  it  as  a  caries 
commencing  in  the  interior  of  the  medullary  canal.  Augustin 
defined  it  as  an  inflammatory  process  in  the  interior  of  bone, 
which,  in  its  course,  brought  about  complete  textural  changes 

CD 


2  TUBERCULOSIS   OF   THE    BONES    AND    JOINTS. 

of  the  parts  affected.  Voigtel  looked  upon  it  as  a  hypertrophic 
process,  in  some  cases ;  in  others,  as  a  softening  of  the  tissues, 
leading  to  perforation  externally.  Boyer  gave  no  definite  opinion 
regarding  the  nature  of  the  disease.  Beclard  thought  that  it 
consisted  of  an  active  proliferation  of  the  endosteum.  Otto 
regarded  it  as  an  internal,  central  caries,  with  expansion  and 
softening  of  the  bone,  accompanied  sometimes  by  the  formation 
of  osteophytes.  Astley  Cooper  described  it  as  a  spongy  exos- 
tosis.  Ph.  v.  Walther  maintained  that  it  is  produced  by  the 
formation  of  a  steatoma  in  the  medullary  tissue.  Lobstein 
recognized  a  total,  central,  cortical,  and  epicortical  spina 
ventosa. 

The  first  accurate  clinical  picture  of  a  tubercular  joint 
was  drawn  by  Wiseman  (several  chirurgical  treatises,  London, 
1676).  He  applied  to  this  affection  the  term  white  swelling 
(tumor  albus),  which,  since  his  time,  until  recently,  and,  to  a 
certain  extent,  even  at  the  present  time,  has  retained  its  place 
in  surgical  nomenclature.  Under  this  term  he  grouped  all 
joint-lesions  characterized  by  chronic  inflammation  and  enlarge- 
ment of  a  joint,  and  maintained  that,  in  the  majority  of  cases, 
it  is  caused  by  scrofula.  He  was  of  the  opinion  that  the  disease 
may  have  its  primary  starting-point  either  in  the  soft  tissues  or 
the  articular  extremities  of  the  bones  composing  the  joint. 
Benjamin  Bell  ("  On  the  Theory  and  Management  of  Ulcers, 
with  a  Dissertation  on  White  Swelling  of  the  Joints."  Edin- 
burgh, 1779)  taught  that  a  tumor  albus  may  be  caused  by  a 
trauma  or  a,  scrofulous  or  rheumatic  inflammation.  Later, 
Laennec,  by  a  stroke  of  genius,  and  profiting  by  the  previous 
labors  of  Bayle,  demonstrated  the  unicity  of  the  tubercular 
process  and  its  various  products, — phthisis,  its  granulations, 
gray  tubercles,  and  caseous  foci, — and  that  most  of  the  lesions 
considered  scrofulous  were,  in  reality,  tubercular  in  their  nature. 
The  fruits  of  this  great  discovery  were  soon  realized  in  surgery. 
Delpech  studied  the  subject  in  its  surgical  aspects.  Michet 
wrote  on  tubercular  ostitis ;  and  Nelaton,  in  his  classical  treatise 


HISTORY.  3 

on  tubercular  affections  of  bone,  applied  to  the  osseous  structure 
the  discovery  of  Laennec,  and  showed  that  in  bone,  as  in  other 
organs,  tubercle  may  appear  either  as  a  circumscribed  or  diffuse 
lesion,  and  that  many  chronic  snppurative  lesions  in  bone  origi- 
nated in  tubercular  foci.  Samuel  Cooper  ("  A  Treatise  on 
Diseases  of  the  Joints."  London,  1807)  called  attention  to  the 
heredity  of  the  scrofulous  predisposition,  and  to  the  influence 
of  traumatic  lesions  in  exciting  a  local  manifestation  of  the 
disease  in  persons  so  predisposed.  Benjamin  Brodie  ("  Patho- 
logical and  Surgical  Observations  on  the  Diseases  of  the  Joints." 
London,  1818)  believed  that  tumor  albus  is  caused  by  a  chronic 
inflammation  of  the  synovial  membrane  in  joints  of  the  same 
character  as  granular  conjunctivitis.  Rust  ("  Arthrokakologie." 
Wien,  1817)  made  a  wide  distinction  between  tumor  albus 
proper  and  scrofulous  inflammation  of  joints.  Bonnet  ("  Traite 
des  Maladies  des  Articulations."  Paris,  1845)  enumerated  scro- 
fula and  tuberculosis  as  causes  of  the  different  forms  of  tumor 
albus.  The  first  anatomical  demonstration  of  the  identity  of  the 
process  in  the  synovial  membrane  in  some  cases  of  tumor  albus, 
with  tubercular  lesions  in  the  lung,  was  furnished  by  Rokitansky 
in  1844.  A  number  of  years  later  Virchow  (Virchow's  Ar- 
chiv,  B.  iv,  S.  312)  pointed  out  that  in  the  most  intractable 
joint-lesions  the  disease  is  caused  by  miliary  tuberculosis  of  the 
synovial  membrane;  and  in  1865  Volkmann  (KranWieiten  der 
Bewegungs  organe  Chirurgie,  von  Pitha-Billroth,  B.  xi,  S.  2. 
Erlangen,  1865)  corroborated  this  statement  by  his  own  observa- 
tions. The  results  obtained  from  the  crude  inoculation  experi- 
ments, which  were  made  by  Villemin  (1865-1869),  pointed 
strongly  toward  the  infectiousness  of  tuberculosis,  and  since  that 
time  diligent  search  was  made  to  discover  and  isolate  a  specific 
micro-organism  which  should  be  characteristic  of  this  disease. 
In  1869,  Koster  (Virchow's  Archiv,  B.  xlviii)  furnished  con- 
vincing proof  that  miliary  tubercles  can  be  found  in  every 
fungous  joint,  and  discovered  and  described  the  giant-cells 
which,  until  recently,  have  been  regarded  as  the  pathogno- 


4  TUBERCULOSIS   OF   THE    BONES    AND   JOINTS. 

monic  histological  element  of  tubercle.  Hueter  (DeutscJie 
Zeitsclirift  f.  Chirurgie,  B.  xi,  S.  317)  and  Schueller  ("  Ex- 
perimentelle  u.  Histologische  Untersuchungen,"  etc.  Stutt- 
gart, 1880)  made  interesting  experiments  to  establish  the  mi- 
crobic  origin  of  tuberculosis,  and  their  work  led  others  to  make 
investigations  in  the  same  direction. 

Lanceraux,  Coyne,  and  Labbe,  in  1873,  showed  the  simi- 
larity existing  between  the  fungous  masses  in  tubercular  joints 
and  in  tendon-sheaths,  and  since  that  time  the  absolute  identity 
of  the  two  analogous  conditions  has  been  made  clear  by  the 
labors  of  Trelat,  Latteau,  Terrier,  and  Verchere.  In  1879, 
Brissaud  and  Josias  published  the  results  of  their  investiga- 
tions, establishing  the  tubercular  nature  of  cold  abscesses.  In 
1879,  Lannelongue  and  Kiener  made  known  their  views  con- 
cerning the  identity  of 'lesions  in  bone  and  joints  that  had 
heretofore  been  regarded  as  of  a  scrofulous  nature,  with  well- 
recognized  tubercular  affections  in  other  organs. 

Volkmann,  Billroth,  and  Konig  made  valuable  clinical 
contributions  which  established  the  tubercular  nature  of  stru- 
mous  disease  of  bone  and  tumor  albus  long  before  the  bacillus 
of  tuberculosis  was  discovered.  Great  activity  was  displayed 
in  all  countries  to  establish  the  parasitic  nature  of  tuberculosis. 

Theories  were  advanced  and  discussed,  microbes  were 
found  and  described,  which  were  supposed  to  bear  a  direct 
etiological  relationship  to  tuberculosis,  but  nothing  definite  was 
known  on  the  subject  until  Robert  Koch,  the  father  of  bacteri- 
ology ("  Die  ^Etiologie  der  Tuberculose."  Berl.  klin.  Wochen- 
schrift,  1882,  No.  15),  in  1882,  announced  to  the  profession  his 
great  discovery.  He  had  found  and  demonstrated  the  true 
cause  of  tuberculosis,  the  bacillus  of  tuberculosis,  and  in  his 
first  publication  brought  such  convincing  proof  of  the  correct- 
ness of  his  claim  that,  with  few  exceptions,  it  brought  convic- 
tion even  to  the  most  skeptical.  He  had  not  only  found  the 
bacillus,  but  showed  that  it  was  constantly  present  in  all  tuber- 
cular lesions.  He  had  isolated  and  cultivated  the  bacillus  from 


HISTORY.  5 

tubercular  tissue,  and  finally  he  had  furnished  the  crucial  test, 
— had  produced  artificial  tuberculosis  in  animals  by  inoculation 
which  was  identical  with  tuberculosis  in  man.  He  examined 
19  cases  of  miliary  tuberculosis,  in  which  bacilli  were  found  in 
every  nodule ;  29  cases  of  pulmonary  phthisis,  in  every  one  of 
which  bacilli  were  found,  most  numerous,  with  the  exception 
of  the  sputum,  in  recent  caseous  foci  and  in  the  walls  of  cav- 
ities undergoing  speedy  destruction.  He  also  found  them  con- 
stantly in  tubercular  ulcers  of  the  tongue,  tubercular  pyelo- 
nephritis, and  tuberculosis  of  the  uterus  and  testicles ;  also,  in 
21  cases  of  tuberculosis  of  lymphatic  glands.  Further,  in  13 
cases  of  tuberculosis  of  joints,  and  in  10  cases  of  tuberculosis 
of  bone ;  in  4  cases  of  lupus,  in  which  only  a  single  bacillus 
could  be  seen  in  the  giant-cells;  in  17  cases  of  perlsuclit  in 
cattle.  Finally,  in  animals  inoculated  with  tubercular  virus: 
273  guinea-pigs,  105  rabbits,  44  field  mice,  28  white  mice,  19 
rats,  13  cats,  besides  dogs,  chickens,  pigeons,  etc.  A  number 
of  pathologists,  who  inoculated  animals  with  non-tubercular 
material,  claimed  that  they  had  produced  pathological  condi- 
tions analagous  to  those  found  in  animals  which  had  been 
infected  with  the  virus  of  tuberculosis.  Further  experimenta- 
tion soon  showed  that  these  were  instances  of  pseudo-tuberculo- 
sis ;  that  while  the  gross  appearances  of  the  lesions  resembled 
true  tuberculosis,  inoculations  with  this  material  never  repro- 
duced the  disease,  while  inoculations  with  tubercular  material 
could  be  done  throng] i  a  series  of  animals  without  impairing 
the  potency  of  the  virus  or  varying  the  constancy  of  the  results. 
Toussaint  showed  that  true  tubercle,  both  in  man  and  animals, 
reproduces  itself  indefinitely  with  absolutely  constant  and  iden- 
tical properties,  and  that  it  is  quite  capable  of  being  transmitted 
from  animal  to  animal  without  losing  its  virulence. 

Koch's  discovery  did  not  lead  to  such  energetic  search  for 
the  bacillus  of  tuberculosis  among  surgeons  as  physicians, 
because,  as  Konig  asserts,  the  symptoms  and  signs  of  the 
tubercular  affections  coming  under  the  notice  of  surgeons  are 


O  TUBERCULOSIS   OF   THE    BONES   AND   JOINTS. 

so  characteristic  that,  for  practical  purposes,  a  correct  diagnosis 
could  be  made  in  a  majority  of  cases  without  a  knowledge  of 
their  microbic  nature  and  the  improved  methods  for  making  a 
positive  diagnosis  derived  therefrom.  Koch  called  special  atten- 
tion to  this  fact,  that  the  bacillus  can  be  constantly  found  in  the 
giant-cells  and  between  the  epithelioid  cells  in  young  tubercles, 
while  it  is  more  difficult  to  find  it  in  cheesy  products,  unless 
caseation  has  taken  place  quite  rapidly.  Schuchardt  and 
Krause  ("  Ueber  das  Vorkomrnen  der  Tuberkelbacillen  bei 
fungosen  und  scrofulosen  Entziindungen."  FortscJiritte  der  Medi- 
cm,  B.  i,  S.  277)  examined  forty  cases  of  tuberculosis  of  bones, 
joints,  tendon-sheaths,  and  the  skin,  in  Volkmann's  clinic,  and 
never  failed  in  finding  bacilli,  although  in  some  specimens  care- 
ful and  prolonged  search  had  to  be  made.  W.  Mueller  and 
Watson  Cheyne  have  demonstrated  experimentally  that  typical 
tuberculosis  of  bones  and  joints  can  be  made  artificially  in 
animals  by  injecting  tubercular  material  or  a  pure  culture  of  tu- 
bercle bacilli  directly  into  the  tissues  or  indirectly  by  the  way  of 
the  arterial  circulation.  It  must  now  be  considered  as  an 
established  fact,  based  on  clinical  observation  and  experimental 
research,  that  all  lesions,  including  affections  of  bones  and  joints, 
in  which  the  microscopical  and  bacteriological  characteristics 
can  be  found,  must  be  regarded  as  tubercular  in  their  origin  and 
tendencies,  thus  establishing  the  microbic  origin  of  tuberculosis 
upon  a  strictly  scientific  basis. 


CHAPTER  II. 

PROOFS  WHICH    ESTABLISH   THE   TUBERCULAR   NATURE   OF   THE 
SO-CALLED  STRUMOUS  DISEASE  OF  BONES  AND  JOINTS. 

FOR  centuries  most  of  the  chronic  inflammatory  affections 
of  bones  and  joints  have,  almost  by  common  consent,  been  re- 
garded as  a  local  manifestation  of  a  general  dyscrasia,  which,  for 
want  of  a  better  knowledge,  was  called  scrofula.  Some  of  the 
text-books  even  at  the  present  time  continue  to  discuss  the  sub- 
ject of  strumous  disease  of  bones  and  joints.  Others,  promi- 
nent among  them,  Sayre,  of  New  York,  and  Bauer,  of  St.  Louis, 
assign  to  trauma  the  principal  role  in  the  production  of  the 
inflammation,  ignoring  the  action  of  a  more  subtle  cause.  I 
will  now  enumerate  the  most  important  evidences  which  tend  to 
establish  the  fact  that  the  diseases  of  bones  and  joints  hereto- 
fore regarded  as  scrofulous  or  strumous  in  their  origin,  or  the 
product  of  a  chronic  inflammation  following  an  injury,  are 
tubercular  in  their  origin  and  their  clinical  tendencies,  and  the 
inflammatory  product  presents  histological  appearances  which 
are  identical  with  the  tissue-lesions  found  in  pulmonary  and 
other  well-recognized  forms  of  tuberculosis  in  other  organs. 

Presence  of  Tubercle  Bacilli  in  the  Affected  Tissues. — 
Tubercle  bacilli  are  only  found  in  the  body  in  connection  with 
tubercular  affections,  and  their  constant  presence  in  the  joint 
and  bone  affections  now  under  consideration  furnishes  a  strong 
proof  of  the  tubercular  nature  of  the  lesions.  Koch,  Krause, 
Schuchardt,  and  Cheyne  always  succeeded  in  demonstrating 
the  presence  of  tubercle  bacilli  in  fungous  disease  of  bones  and 
joints. 

Koch  ("Die  JEtiologie  der  Tuberciilose,"  Mittli.  aus  dem 
Kais.  Gesundheitsamte,  B.  xi,  S.  1-188.  Berlin,  1884)  gives 
the  result  of  his  examination  of  thirteen  specimens  of  bone  and 
joint  tuberculosis.  He  found  tubercle  bacilli  within  giant- 
cells  and  between  epithelioid  cells  and  the  cheesy  material  in 

m 


8  TUBERCULOSIS   OF   THE   BONES    AND    JOINTS. 

all  of  them  except  one,  and  this  was  a  case  of  tubercular  abscess 
of  the  vertebrae  in  which  no  bacilli  could  be  found  in  the  pus, 
but  inoculation  experiments  yielded  positive  results. 

Castro-Soffia  ("Recherches  experimentales  sur  la  tuber- 
culose  des  Os."  These  de  Paris,  1885)  was  one  of  the  first  to 
make  a  careful  methodical  search  for  the  bacillus  in  tubercular 
lesions  of  bone.  As  the  result  of  quite  an  extensive  clinical  inves- 
tigation he  assures  us  that  he  never  failed  in  demonstrating  the 
presence  of  the  microbe,  not  only  by  microscopical  examination, 
but  also  by  inoculation  experiments.  In  this  connection  it  is 
well  to  mention  incidentally  that  Schuchardt  and  Krause 
(Fortschritte  der  Medicin,  May,  1883)  have  examined  specimens 
from  forty  cases  of  surgical  tuberculosis  in  the  clinics  at  Halle 
and  Breslau ;  they  comprise : — 

Synovial  tuberculosis,      .        .  -      .        .        .  10  cases. 
Osseous  tuberculosis,        .     '  .    .     .        .        .          3 
Glandular  tuberculosis,    .        ...        .          3 

Cold  abscesses,          .        .        ,        .        .        .  14 

Tubercle  of  muscle, 1  case. 

Tubercle  of  tongue, 1 

Tubercle  of  testicle,         .        .        .        .        .          I 
Tubercle  of  female  genitalia,  .        .        .        .          1 

Miscellaneous, 6  cases. 

Total, ~4(T    " 

In  every  one  of  these  cases  they  found  the  characteristic 
bacilli. 

Schlegtendal  ("  Ueber  das  Vorkommen  der  Tuberkelbacil- 
len  im  Eiter."  Fortschritte  der  Medicin,  B.  i,  S.  537)  exam- 
ined five  hundred  and  twenty  specimens  of  pus  from  tubercular 
abscesses,  and  found  bacilli  present  in  about  75  per  cent,  of  the 
cases.  As  the  bacilli  are  never  as  numerous  in  tubercular  pus 
as' in  the  granulation  tissue,  there  can  be  but  little  doubt  that 
in  the  remaining  25  per  cent,  of  the  cases  they  were  present, 
but  were  not  discovered ;  or,  perhaps,  that  in  some  of  them  the 
primary  lesion  was  not  of  a  tubercular  nature.  Experiments 
have  repeatedly  shown  that  pus  from  tubercular  lesions  in  which 
no  bacilli  could  be  found  produced,  when  injected  into  the 


SO-CALLED    STRUMOUS    DISEASE    OF    BONES   AND   JOINTS.  9 

tissues  of  animals  susceptible  to  inoculation,  typical  tuberculo- 
sis,— a  positive  demonstration  that  the  material  injected  con- 
tained the  essential  cause  of  the  disease. 

W.  Mueller  ("  Ueber  den  Befund  von  Tuberkelbacillin  bei 
fungosen  Knochen  u.  Gelenkaffectionen."  Centralblatt  f. 
Chirurgie,  No.  3,  1884)  has  learned,  from  his  own  experience 
in  the  examination  of  numerous  specimens  of  tuberculosis  of 
bones  and  joints,  that  it  is  very  difficult  to  find  the  tubercle 
bacilli  in  some  of  them.  In  about  twenty  specimens  he  failed  to 
find  them  ;  nevertheless,  he  believes  that  they  were  tubercular, 
and  that  the  bacilli  were  so  few  in  number  that  their  detection 
was  difficult,  or  that  they  were  not  properly  stained.  In  many 
of  the  specimens  he  found  masses  resembling  drops  of  fat  sur- 
rounded by  fine  granules,  which  could  be  deeply  stained  with 
methyl-violet,  and  expressed  the  opinion  that  these  bodies  were 
fragments  or  parts  of  bacilli,  and  were  capable  of  reproducing 
the  disease  in  animals  by  inoculation. 

Mogling  ("  Die  Chirurgischen  Tuberculosen."  Tubingen, 
1884)  found  the  bacilli  never  absent  in  tubercular  pus  from 
fifty-three  patients. 

Among  others  who  have  shown  the  never-failing  presence 
of  the  bacillus  in  different  forms  of  surgical  tuberculosis,  includ- 
ing bones  and  joints,  may  be  mentioned  Kanzler,  Bouilly,  and 
Letulle.  Tuberculosis  of  bone  and  fungous  disease  of  the 
joints,  like  lymphatic  tuberculosis,  have  been,  and  by  some  are 
still,  regarded  as  scrofulous  affections.  Kanzler  wished  to  make 
a  distinction  between  scrofula  and  tuberculosis,  as  he  found 
bacilli  not  as  constant  in  the  former,  and  observed  that,  after 
implantation  of  tissue  of  what  he  regarded  as  scrofulous  affec- 
tions in  animals,  the  process  was  slower  than  after  inoculation 
with  the  products  of  recognized  forms  of  tuberculosis.  Letulle 
considers  scrofula  and  tuberculosis  as  belonging  to  one  and  the 
same  disease,  of  which  the  former  constitutes  the  milder  form 
and  appearing  externally,  while  the  latter  represents  the  graver 
form,  attacking  by  preference  the  internal  organs.  The  points 


10  TUBERCULOSIS   OF   THE   BONES    AND    JOINTS. 

made  by  the  last  two  authors  are  too  unimportant  for  further  con- 
sideration as  a  scientific  or  even  practical  distinction  between 
scrofula  and  tuberculosis  as  applied  to  affections  of  the  bones 
and  joints.  The  surgeon  must  recognize  every  lesion  as  tuber- 
cular in  its  origin,  nature,  and  course  in  which  the  bacillus  of 
tuberculosis  can  be  found,  from  which  successful  cultivations  can 
be  made,  and  with  which  the  disease  can  be  artificially  produced 
in  animals  by  inoculation. 

Watson  Cheyne  asserts  that  as  the  result  of  Ids  numerous 
experiments  bacilli  can  always  be  found  in  the  tissue-lesions,  but 
that  in  most  cases  they  were  extremely  few  in  number.  He 
believes  that  the  difficulty  in  finding  them  more  constantly  and 
in  greater  number  is  owing  to  our  present  defective  means  for 
staining  them. 

Direct  Infection  of  a  Joint  through  a  Wound  or  Extension 
of  Disease  to  it  from  a  Tubercular  Focus  near  a  Joint. — A  few 
well-authenticated  cases  are  on  record  in  which  infection  occurred 
by  the  entrance  of  the  tubercular  virus  into  a  joint  through  a 
penetrating  wound.  Middledorpf  ("  Ein  Fall  von  Infection 
einer  penetrirenden  Kniegelenkswunde  durch  tuberculoses 
Virus."  Fortschritte  der  Medicin,  1886)  reports  the  case  of  a 
healthy  carpenter  who  opened  his  knee-joint  by  the  cut  of  an 
axe  and  dressed  the  wound  with  a  soiled  handkerchief.  The 
wound  healed  kindly,  but  later  the  joint  became  swollen,  tender, 
and  painful.  Resection  was  performed,  and  on  examining  the 
capsule  it  was  found  very  much  thickened.  In  the  granulation 
tissue  bacilli  were  found.  Czerny  (Centralblatt  f.  Chirurgie, 
1886)  relates  two  cases  in  which  tuberculosis  followed  in  granu- 
lating surfaces  treated  by  Reverdin's  transplantation  of  skin. 
In  both  instances  the  patients  were  healthy,  and  the  skin  trans- 
plantation was  made  during  the  treatment  of  extensive  burns. 
The  skin  was  taken  from  limbs  amputated  for  tubercular  affec- 
tions. In  both  cases  tuberculosis  of  the  adjacent  joint  occurred, 
and  in  one  of  them  tuberculosis  of  the  granulating  surface. 
Verneuil  refers  to  the  case  of  a  student  who  injured  the  fold  of 


SO-CALLED    STRUMOUS    DISEASE    OF    BONES   AND   JOINTS.          11 

the  nail  of  his  right  ring-finger  at  a  post-mortem,  with  the  result 
of  causing  a  local  tuherculosis  of  the  skin.  This  was  treated  in 
various  ways  without  permanent  improvement,  and,  after  treat- 
ment of  three  years,  there  was  still  a  tubercular  ulcer  on  the 
finger  and  a  tubercular  abscess  on  the  back  of  the  hand.  This 
abscess  was  opened  and  the  ring-finger  was  amputated,  but 
chronic  abscesses  continued  to  form,  and  the  patient  died,  six 
years  after  the  injury,  of  spinal  meningitis,  due  to  suppuration 
in  connection  with  tubercular  disease  of  the  vertebrae. 

In  Pfeiffer's  case,  a  veterinary  surgeon,  without  any  heredi- 
tary tendency  to  tuberculosis,  punctured  the  phalangeal  joint 
of  his  thumb  while  dissecting  a  tubercular  cow.  The  wound 
soon  healed,  but  the  joint  became  the  seat  of  a  tubercular 
inflammation.  Some  months  later  symptoms  of  pulmonary 
phthisis  set  in,  and  he  died  a  year  and  a  half  after  the  injury. 
The  infected  joint  showed  all  the  macroscopical  and  microscopi- 
cal appearances  of  typical  tubercular  disease.  Barker's  ("  Three 
Lectures  on  Tubercular  Joint  Disease  and  its  Treatment  by 
Operation."  British  Medical  Journal,  1888,  vol.  i,  pp.  1202, 
1259,  1322)  case  was  that  of  an  assistant  in  the  post-mortem 
room,  aged  54,  with  good  family  history,  who  first  inoculated 
his  finger  ten  to  fourteen  years  previously,  and  at  that  time  the 
tubercular  papilloma  healed.  Seven  or  eight  years  before  his 
admission  into  the  hospital  he  acquired  another  wart,  which, 
however,  disappeared  under  treatment,  but  had  previously 
'extended  to  the  wrist,  necessitating  a  resection  of  this  joint. 
If  a  tubercular  focus  in  bone  or  in  the  soft  tissues  near  a 
joint  perforates  into  a  joint  infection  occurs  at  once,  and  the 
joint  disease  which  ensues  resembles  the  primary  extra-articular 
lesion  in  every  respect,  showing  conclusively  that  it  resulted  from 
the  same  essential  cause. 

Inoculation  Experiments. — One  of  the  most  convincing 
evidences  in  support  of  the  identity  of  fungous  joint  disease 
with  well-recognized  tubercular  lesions  in  other  organs  is  the 
fact  that  implantation  of  fragments  of  the  diseased  synovial 


12  TUBERCULOSIS    OF    THE    BONES   AND   JOINTS. 

membrane  into  the  subcutaneous  tissue  or  peritoneal  cavity  of 
animals  susceptible  to  tuberculosis  almost  without  exception 
reproduces  the  disease  in  the  animal. 

Inoculation  experiments  have  shown  that  it  is  necessary  to 
inject  a  certain  quantity  of  tubercular  material  or  tubercle  ba- 
cilli in  animals  in  order  to  produce  a  positive  result,  which  goes 
to  prove  that  healthy  tissues  are  capable  of  disposing  of  a  non- 
pathogenic  dose  of  the  tubercular  virus.  Gerhardt  experimented 
with  the  milk  of  tubercular  cows,  and  found  that,  in  cases  where 
the  original  milk  was  virulent,  it  produced  no  effect,  whether 
injected  subcutaneously  or  into  the  peritoneal  cavity,  when  it 
was  diluted  forty  times  or  more.  In  experiments  on  feeding 
animals  with  phthisical  sputum,  he  found  that  infection  did  not 
occur  when  the  sputum  was  diluted  more  than  eight  times, 
although  the  same  sputum  diluted  one  hundred  thousand  times 
caused  infection  when  injected  subcutaneously.  He  has  also 
ascertained  that  the  disease  runs  a  much  slower  course  when 
the  number  of  bacilli  originally  introduced  was  very  small. 
Wyssokowitsch  found  that  it  was  necessary  to  inject  more  than 
forty  tubercle  bacilli  into  the  veins  of  rabits  in  order  to  produce 
infection,  and  he  makes  the  same  observations  as  to  the  more 
severe  character  of  the  disease  the  greater  the  number  of  bacilli 
primarily  introduced.  It  has  further  been  shown  that  the 
endothelium  of  the  blood-vessels  takes  up  microbes  floating  in 
the  blood,  and  this  fact  is  of  great  interest  in  connection  with 
the  development  of  tubercles  from  the  vascular  endothelium. 

According  to  Pawlowsky  (kt  Experimental  Contribution  to 
the  Pathogenesis  of  Joints."  Annals  of  Surgery,  vol.  x,  p. 
225)  an  intra-articular  injection  of  a  pure  culture  of  tubercle 
bacilli  in  animals  produces  a  well-marked  incipient  tubercular 
inflammation  of  the  sy  no  vial  membrane  at  the  end  of  the 
fourth  day.  About  the  sixth  day  the  membrane  becomes  rough 
and  grayish,  while  there  appears  sometimes  serous  effusion  into 
the  joint,  and  swelling  of  the  adjacent  lymphatic  glands.  On 
the  twelfth  day  he  found  joints  thus  artificially  injected  dis- 


SO-CALLED    STRUMOUS   DISEASE   OF   BONES   AND   JOINTS.          13 

tended  with  fluid,  and  the  para-articular  tissues  swollen  and 
cedematous.  By  the  end  of  three  weeks  the  process  advanced 
to  the  formation  of  granulation  tissue  and  beginning  suppura- 
tion. Microscopical  examination  of  the  synovial  membrane 
shows  that  the  bacilli  invade  the  tissues  along  the  course  of 
lymphatic  vessels  and  connective-tissue  spaces.  General  infec- 
tion is  prevented  indefinitely  by  a  zone  of  lymphatic  glands. 

Tavel  (Senn :  "  Four  Months  Among  the  Surgeons  of 
Europe,"  p.  154.  Chicago,  1887)  has  for  several  years  re- 
sorted to  implantation  experiments  as  a  means  of  diagnosis  in 
obscure  cases,  and  the  results  obtained  have  yielded  infallible 
diagnostic  information.  Granulation  tissue  from  tubercular 
joints  in  his  experiments  on  guinea-pigs  invariably  produced 
acute,  diffuse  tuberculosis,  and  death  in  from  five  to  six  weeks. 
The  course  of  the  disease  in  the  animal  is  typical ;  at  the  point 
of  inoculation  a  hard  nodule  appears  first,  the  result  of  a  trau- 
matic inflammation  of  the  tissues  around  the  graft.  Next,  a 
lymphatic  gland  becomes  enlarged  in  the  immediate  vicinity  of 
the  primary  seat  of  infection,  which  was  invariably  the  in- 
guinal region  ;  consequently,  the  inguinal  glands  enlarged  first. 
Glandular  infection  increases  rapidly ;  after  the  whole  chain  of 
lymphatic  glands  in  the  groin  are  involved,  the  axillary  glands 
become  affected.  Death  occurs  in  the  course  of  five  or  six 
weeks.  At  the  post-mortem  it  was  always  found  that  of  the 
internal  organs  the  spleen  becomes  affected  first,  then  the  liver 
and  lungs,  but  usually  the  disease  is  so  diffuse  that  scarcely  an 
organ  remains  entirely  exempt.  When  the  diagnosis  between 
a  syphilitic  and  tubercular  disease  of  a  bone  or  joint  cannot  be 
made  either  clinically  or  by  aid  of  the  microscope,  inoculation  ex- 
periments always  give  positive  and  reliable  information.  When 
the  lesion  is  tubercular  the  disease  is  always  communicated  to  the 
animal  through  the  graft,  and  the  animal  dies  of  miliary  tuber- 
culosis within  six  weeks.  When  it  is  syphilitic,  the  inoculation 
is  harmless  and  the  animal  remains  well.  At  the  time  Tavel 
communicated  these  facts  to  me,  only  one  guinea-pig  that  was 


14  TUBERCULOSIS   OF   THE    BONES    AND    JOINTS. 

inoculated  with  tubercular  material  had  survived  the  infection 
and  was  living  at  the  end  of  five  months,  and  in  this  case  a  large 
abscess  formed*  at  the  point  of  inoculation  a  few  weeks  later. 
Examination  of  the  contents  of  the  abscesses  showed  a  large 
number  of  bacilli ;  a  gland  in  the  groin  remained  enlarged,  and 
the  disease,  if  not  arrested  by  the  suppurative  inflammation,  had 
probably  passed  into  a  latent  stage. 

In  Kocher's  wards  at  Berne  (British  Medical  Journal, 
June  29,  1888),  the  inoculation  of  guinea-pigs  has  been  em- 
ployed for  some  time  as  a  bacteriological  test  of  the  existence  of 
tubercular  disease,  such  animals  being  very  susceptible,  and  the 
development  of  the  affection  in  them  being  rapid  enough  to 
permit  of  a  positive  diagnosis  being  made  in  from  two  to  four 
weeks.  From  the  results  obtained  in  one  hundred  and  twenty 
cases  where  this  diagnostic  inoculation  was  practiced,  from  one 
to  five  animals  being  used  in  each  case,  Tavel  lays  down  the 
following  propositions:  1.  If  the  case  is  of  a  tubercular  nature, 
inoculation  invariably  gives  rise  to  the  development  of  tuber- 
culosis in  the  animal  experimented  upon.  2.  The  method  re- 
quires far  less  time  and  trouble,  and  gives  more  trustworthy 
results  than  microscopic  examination.  3.  The  method  is  certain, 
even  where  anatomical  examination  is  practically  impossible. 

Cheyne  has  been  equally  successful  in  transferring  the  dis- 
ease from  man  to  animal  by  implantation  of  granulation  tissue 
from  tubercular  bones  and  joints.  Inoculation  experiments  are 
equally  valuable  in  making  a  differential  diagnosis  between  true 
and  tubercular  abscess.  If  a  hypodermatic  syringe  is  filled  with 
the  contents  of  an  abscess  from  a  case  in  which  it  is  necessary 
to  make  a  correct  diagnosis,  and  the  injection  is  made  into  the 
peritoneal  cavity  of  a  guinea-pig,  the  result  following  will  make 
a  positive  diagnosis.  If  it  is  true  pus,  the  injection  will  either 
be  harmless,  if  the  peritoneal  cavity  possesses  sufficient  absorp- 
tive capacity  to  absorb  the  pus  and  eliminate  the  pus-microbes, 
or  a  circumscribed  or  diffuse  suppurative  peritonitis  will  follow 
promptly.  If,  on  the  other  hand,  the  abscess  is  tubercular  the 


SO-CALLED    STRUMOUS   DISEASE   OF    BONES   AND   JOINTS.          15 

injection  will  produce  a  typical  tubercular  peritonitis  and  death 
from  miliary  tuberculosis. 

Artificial  Production  of  Bone  and  Joint  Tuberculosis  in 
Animals  by  Direct  Inoculation. — It  has  already  been  shown  that 
tubercular  joint  disease  in  man  has  been  caused  by  direct  inocu- 
lation of  the  joint  through  a  penetrating  wound  or  extension  of 
the  disease  to  it  from  an  extra-articular  focus  near  to  it.  The 
same  results  have  been  produced  in  animals  artificially  by  direct 
inoculation.  Hueter  ("  Ueber  scrophulose  u.  tuberculose  Gelen- 
kentzimdung."  Verh.  der  DeutscJien  Gesellschaft  f.  Oliirurgie, 
B.  vii,  S.  107)  was  positive  in  his  assertions  that  scrofulous  and 
tubercular  affections  of  joints  were  identical  anatomically  and 
etiologically.  He  succeeded  regularly  in  producing  tuberculosis 
of  the  iris  by  implanting  into  the  anterior  chamber  of  the  eye 
in  rabbits  fragments  of  granulation  tissue  taken  from  a  fungous 
synovial  membrane.  Schueller  ("Untersuchungen  iiber  die 
Entstehung  und  Ursache  der  scrofulosen  und  tuberculosen 
Gelenkleiden,"  1880)  claimed  in  1880  to  have  discovered  the 
microbe  of  tuberculosis  by  fractional  cultivation  from  lupus- 
tissue,  which  when  conveyed  into  the  vessels  of  the  lungs  pro- 
duced phthisis,  and  when  injected  into  joints  tubercular  inflam- 
mation, caseation,  and  finally  miliary  tuberculosis. 

The  same  author  ("  Experimentelle  und  Histologische 
Untersuchungen  iiber  Entstehung  der  Skrofulosen  u.  Tubercu- 
losen Gelenkleiden."  Stuttgart,  1880)  studied  the  localization 
of  the  tubercular  virus  experimentally  in  the  same  manner  as 
others  have  studied  the  localization  of  pus-microbes.  He  in- 
oculated animals  with  the  products  of  tubercular  inflammation, 
subsequently  produced  contusions  and  sprains  of  joints,  and 
observed  that  localization  usually  occurred  at  the  seat  of  injury. 
If  the  tubercular  virus  was  introduced  by  inhalation,  the  same 
typical  lesions  occurred  in  the  injured  joints  as  when  injec- 
tion was  made  more  directly.  In  all  cases  the  products  of  the 
local  lesion  corresponded  with  the  character  of  the  material 
introduced  through  some  remote  point. 


16  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

W.  Mueller  ("  Experimentelle  Erzeugiing  der  typischen 
Knochentuberculose."  Centralblatt  f.  Chirurgie,  1886,  p.  233) 
produced  experimentally  the  typical  form  of  tuberculosis  in 
bone  by  the  injection  of  tubercular  material  into  the  nutrient 
artery  of  the  tibia.  Konig  has  claimed  for  a  long  time  that 
the  wedge-shaped  sequestrum  so  frequently  found  in  tubercular 
foci  in  the  articular  extremities  of  the  long  bones  was  due  to 
occlusion  of  a  small  artery  by  a  tubercular  embolus.  Mueller 
proved  the  correctness  of  this  conclusion  derived  from  clinical 
observation  by  experimentation.  He  made  sixteen  experiments 
on  rabbits,  injecting  tubercular  pus  into  the  femoral  artery,  some 
in  a  peripheral,  some  in  a  central,  direction,  without  any  posi- 
tive results.  In  a  second  series  the  same  material  was  thrown 
into  the  nutrient  arteries  of  the  femur  and  tibia.  Of  ten  of 
these  cases,  two  showed  a  tubercular  focus  in  the  medulla  of  the 
diaphysis  of  the  tibia ;  in  another  case  miliary  tuberculosis  in 
the  femur  and  tibia,  and  in  the  latter  bone  a  small  caseous  spot 
in  the  spongy  part,  which  contained  numerous  bacilli.  The 
animals  were  killed  eight  weeks  after  the  injection,  and  showed 
no  evidences  of  organic  disease,  except  a  few  tubercles  in  the 
lungs.  Twenty  experiments  were  made  on  young  goats,  five  on 
sheep,  and  two  on  dogs.  The  tubercular  material  was  injected 
directly  into  the  nutrient  artery  of  the  tibia,  the  tibial  artery 
being  tied  above  and  below  the  vessel.  Primary  union  of  the 
wound  was  obtained  in  all  cases  except  in  one  dog.  In  the  dogs 
and  sheep,  all  experiments  yielded  negative  results.  In  the 
goats,  bone  affections  were  produced  which  were  identical  with 
tubercular  bone-lesions  found  in  man.  Most  frequently  the 
disease  was  established  in  the  diaphysis,  cheesy  masses  and 
granulation  tissue  showing  themselves 'in  the  medulla,  the  result 
of  tubercular  osteomyelitis  with  or  without  sequestration. 
Typical  lesions  were  also  found  in  the  ends  of  the  bones,  with 
and  without  implication  of  the  adjacent  joints.  In  two  of  these 
cases  the  epiphysis  was  aifected,  while  in  three  the  shaft  alone 
was  involved.  The  following  experiment  furnishes  a  good  illus- 


SO-CALLED    STRUMOUS    DISEASE   OF    BONES   AND   JOINTS.          17 

tration  of  the  identity  of  the  bone  disease  produced  experiment- 
ally and  the  disease  as  it  occurs  in  man.  Tubercular  material 
was  injected  into  the  tibial  artery  of  a  goat  three  months  old. 
Wound  healed  in  eight  days.  Some  lameness  four  months 
later,  gradually  increasing  during  the  next  nine  months.  At 
the  same  time  a  swelling  appeared  at  the  knee-joint.  Tibia 
painful  on  outer  side.  Animal  killed  thirteen  months  after  the 
injection.  There  was  found  a  typical  fungous  disease  in  the 
knee-joint  most  advanced  at  the  sides,  a  wedge-shaped  seques- 
trum in  one  of  the  tuberosities  of  the  tibia,  and  a  small  granu- 
lation mass  in  the  centre  of  the  head  of  the  tibia,  and  two 
similar  granulating  foci  in  the  lower  epiphysis  of  the  femur. 
With  the  exception  of  the  lymphatic  glands  of  the  knee-joint, 
no  other  organs  were  affected.  In  some  cases  pulmonary  tuber- 
culosis developed,  twice  general  miliary  tuberculosis.  The  rest 
of  the  animals  were  killed  when  they  began  to  show  lameness, 
—fourteen  days  to  thirteen  months  after  the  inoculation.  The 
tubercular  lesions  thus  produced  were  examined  for  bacilli,  and 
these  were  constantly  found.  The  starting-point  in  every 
instance  must  have  been  a  tubercular  embolus  in  one  of  the 
small  arterial  branches  in  the  extremity  of  the  affected  bone. 
Phthisical  sputum  or  a  pure  culture  of  tubercle  bacilli  injected 
directly  into  a  bone  or  joint  will  produce  a  localized  tuberculosis 
in  rabbits,  goats,  and  other  animals  susceptible  to  infection. 

Cheyne  (British  Medical  Journal,  April  11,  1891)  injected 
tubercular  sputum,  diluted  with  distilled  water,  into  the  knee- 
joints  of  two  rabbits,  and  produced  in  this  way  a  typical  synovial 
tuberculosis,  with  extension  of  the  disease  later  to  the  cartilages 
and  articular  extremities.  In  two  rabbits,  holes  were  drilled  in 
the  upper  part  of  the  tibia  and  tubercular  sputum  injected  into 
the  interior  of  the  bone.  In  the  first  experiment  the  result  was 
very  slight ;  the  second  animal  showed,  in  a  short  time,  evi- 
dences of  a  positive  result,  and  was  killed  ninety-one  days  after 
inoculation.  The  specimen  revealed  a  focus  of  tuberculosis  in 
the  interior  of  the  bone,  at  the  point  of  inoculation,  which  had 


18  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

extended  to  the  epiphysis  and  finally  to  the  synovial  membrane, 
at  a  point  corresponding  to  the  posterior  recess  of  the  capsule 
of  the  joint.  The  results  obtained  in  four  guinea-pigs  were  not 
as  typical  as  in  the  rabbit.  Injection  of  an  emulsion  of  tubercu- 
lar pus  in  distilled  water  into  the  femoral  artery  of  a  rabbit  pro- 
duced a  cheesy  mass  in  the  upper  part  of  the  tibia,  just  below 
the  epiphysial  line.  There  was  no  tuberculosis  in  any  of  the 
internal  organs.  Injection  of  an  emulsion  of  a  pure  culture  of 
tubercle  bacilli — made  by  taking  the  culture  from  a  tenth  series 
of  tubes  from  Koch's  laboratory  and  rubbing  it  up  in  distilled 
water — into  the  knee-joints  of  a  number  of  rabbits  produced  in 
every  instance  typical  tuberculosis,  followed  by  extension  of  the 
disease  to  the  cartilages  and  articular  extremities  of  the  bones. 
In  three  cases  a  similar  injection  was  made  into  the  lower 
epiphysis  of  the  femur,  and  in  each  instance  with  positive  re- 
sults. The  experiments  made  on  goats,  by  injecting  the  tuber- 
cular material  directly  into  joints,  nutrient  artery  of  tibia,  and 
epiphysial  extremities  of  the  long  bones,  yielded  positive  results. 
Krause  ("  Die  Tuberkulose  der  Knochen  und  Gelenke." 
Leipzig.  1891)  produced  tuberculosis  of  joints  in  rabbits  by 
injecting  pure  cultures  suspended  in  distilled  water.  Two 
weeks  after  the  injection  he  found  the  joint  swollen,  and  the 
animal  dragged  the  leg  in  walking.  The  swelling  increased 
quite  rapidly,  and  the  temperature  of  the  surface  of  the  joint 
was  increased.  As  a  rule,  flie  animal  died  in  from  four  to  five 
weeks.  In  every  specimen  examined  the  para-articular  tissues 
were  much  swollen,  and  in  one  of  the  animals  an  abscess  had 
formed  outside  of  the  joint.  The  synovial  membrane  was 
always  found  swollen  and  very  vascular,  but  its  inner  surface  was 
usually  smooth.  In  the  superficial  layers  miliary  nodules  are 
few  ;  but  these  were  more  numerous  near  the  surface.  Some  of 
the  nodules  were  larger  and  showed  central  caseation.  The 
histological  structure  of  the  nodules  was  typical.  In  guinea- 
pigs  he  infected  the  animals  by  injecting  a  pure  culture  into  the 
subcutaneous  connective  tissue  in  one  of  the  inguinal  regions. 


SO-CALLED    STRUMOUS    DISEASE   OF    BONES    AND   JOINTS.          19 

Ten  days  after  the  injection  a  nodule  formed  at  the  point  of 
puncture,  followed  by  infection  of  the  inguinal  glands.  About 
the  eleventh  day  he  produced  injuries  of  joints  and  bones,  such 
as  sprains,  contusions,  and  fractures.  In  rabbits  the  injuries 
were  preceded  by  intra-peritoneal  or  intra-venous  injections  of 
pure  cultures.  The  latter  method  of  injection  was  often  fol- 
lowed by  death  from  acute  miliary  tuberculosis  before  the  process 
had  time  to  locate  at  the  seat  of  injury.  The  animals  that  sur- 
vived the  injection  three  to  seven  weeks  furnished  positive  results 
in  reference  to  disease  of  the  injured  joints  and  bones.  Of  fifteen 
guinea-pigs  that  were  inoculated,  and  in  which  injuries  of  bones 
and  joints  were  produced,  and  that  died  of  general  tuberculosis, 
only  in  one  were  the  bones  and  joints  intact.  The  fractures  united 
by  bony  callus ;  the  process  of  repair  showed  no  deviation  from 
that  in  healthy  animals.  There  were  no  evidences  of  tubercular 
disease.  Of  three  dislocations  of  large  joints,  only  in  one  was  the 
capsule  the  seat  of  tubercular  disease.  Of  forty-four  sprained 
joints,  only  fifteen  became  tubercular.  In  these  cases  the  syno- 
vial  membrane  was  infiltrated  with  round-cells  and  quite  vascu- 
lar. The  nodules,  which  often  attained  considerable  size,  were 
made  up  of  round  and  epithelioid  cells.  In  the  centre  of  the 
larger  nodules  was  incipient  caseation  ;  no  giant-cells ;  tubercle 
bacilli  always  present,  but  few  in  number;  articular  cartilages 
normal.  In  six  cases  there  was  well-marked  tuberculosis  in  the 
medulla  of  the  epiphysial  extremities  of  the  long  bones.  Bacilli 
in  this  locality  were  as  scanty  as  in  the  synovial  membrane. 

In  one  specimen  in  the  lower  end  of  the  femur  he  found 
three  emboli  which  contained  tubercle  bacilli.  In  the  rabbits 
that  were  inoculated  he  produced  twenty-eight  sprains  in  as 
many  different  joints,  and  found  later  tubercular  lesions  in  half 
of  the  injured  joints.  The  fractures  made  in  these  animals 
healed  in  the  same  manner  as  in  the  guinea-pigs,  by  bony  union 
without  a  sign  of  tuberculosis,  although  tubercles  in  the  medul- 
lary tissue  were  found  more  frequently  than  in  the  guinea-pigs; 
but  these,  when  present,  were  always  found  from  one  to  several 


20  TUBERCULOSIS   OF   THE    BONES    AND   JOINTS. 

centimetres  distant  from  the  fracture.  In  the  joints  thus  in- 
fected the  disease  was  limited  to  the  synovial  membrane.  Casea- 
tion  appeared  sooner  than  in  the  guinea-pigs.  Of  seventy-nine 
distortions  of  joints  in  rabbits  and  guinea-pigs,  only  in  twenty- 
nine  did  the  injured  joint  become  the  seat  of  disease,  although 
all  of  the  animals  died  of  general  tuberculosis.  Only  in  a  single 
case,  in  a  rabbit,  did  a  healthy  joint  become  the  seat  of  tuber- 
cular infection ;  in  all  the  other  cases  the  injury  determined  the 
localization. 

Association  of  Bone  and  Joint  Tuberculosis  with  Tnbercu~ 
losis  in  Other  Organs. — The  frequency  with  which  joint  and 
bone  tuberculosis  gives  rise  to  tuberculosis  in  other  organs  points 
to  a  direct  etiological  relationship  between  the  primary  and 
secondary  affection.  Every  surgeon  is  also  conversant  with  the 
familiar  clinical  fact  that  bone  and  joint  affections  frequently 
develop  in  the  course  of  tubercular  affections  in  other  organs, 
showing  again  a  causative  connection  between  the  primary  and 
secondary  disease.  Cheyne  (British  Medical  Journal,  April  11, 
1891,  p.  790)  states  that,  of  386  patients  suffering  from  bone  or 
joint  tuberculosis  observed  for  a  period  of  three  years,  after  the 
termination  of  treatment,  forty-two,  or  10  per  cent.,  had  become 
affected  with  or  had  died  of  phthisis  or  some  other  form  of  tuber- 
culosis. Billroth  and  Menzel  found,  on  searching  the  post- 
mortem records  at  Vienna  for  a  period  of  50  years  (1817-1867), 
that  there  had  been  2106  cases  of  caries  of  bones  and  joints, 
and  of  these  more  than  half  were  complicated  with  tuberculosis 
of  the  internal  organs.  Neumeister  has  collected  438  cases 
from  the  Wiirzburg  clinic  and  other  sources,  with  sixty,  or  15 
per  cent.,  of  deaths  from  acute  tuberculosis.  Willemer  has 
ascertained,  from  statistics  which  he  collected  and  studied,  that  in 
the  case  of  chronic  affections  of  the  knee-joint,  1  per  cent,  of 
the  patients  die  of  tuberculosis  during  the  first  year  of  the  disease, 
7  per  cent,  during  the  second,  6  per  cent,  during  the  third, 
making  a  mortality  of  14  per  cent,  from  acute  tuberculosis 
within  three  years.  Konig  states  that  in  only  21  per  cent,  of 
all  cases  of  joint  tuberculosis  is  the  disease  confined  to  the  joint. 


SO-CALLED    STRUMOUS   DISEASE   OF    BONES   AND   JOINTS.         21 

Microscopical  Structure  of  Diseased  Tissue  and  Caseation 
of  Inflammatory  Product.  —  Rokitansky,  Virchow,  Koster, 
Kiener,  and  others  have  shown  that  the  primary  nodules  in 
bone  and  synovial  membrane  during  the  early  stages  of  tuber- 
cular disease  show,  under  the  microscope,  the  same  structure  as 
miliary  tubercle  in  the  lungs.  The  primary  inflammatory 
product  is  a  minute  tubercle,  in  which  the  same  histological 
elements  can  be  found  and  can  be  seen  to  be  arranged  in  a 
similar  manner  as  in  miliary  tubercles  in  the  lung.  The 
primary  tubercle  here,  like  in  the  mng,  is  an  avascular  struc- 
ture, and  undergoes  the  same  secondary  pathological  changes 
as  in  the  latter  organ.  Coagulation  necrosis  and  caseation 
of  the  inflammatory  product  takes  place,  slower,  but  with  the 
same  regularity  in  tubercular  products  in  bone  and  joints  as  in 
pulmonary  phthisis.  The  very  fact  that  the  inflammatory 
product  in  bone  and  joint  tuberculosis  presents  the  same  histo- 
logical  structure,  and  is  subject  to  the  same  pathological  changes 
as  tubercle  in  the  lungs,  warrants  the  assertion  that  they  are 
produced  by  the  same  cause  and  undergo  analogous  degenerative 
processes. 

Reaction  to  Tuberculin. — One  of  the  benefits  derived  from 
the  treatment  of  tubercular  affections  with  Koch's  lymph  is  the 
knowledge  gained,  that  tubercular  affections  of  bone  and  joints 
react  under  the  use  of  tuberculin  in  the  same  manner  and  with 
the  same  promptness  as  tubercular  lesions  in  the  lungs.  The 
general  reaction  is  often  very  intense,  as  I  have  observed  a  tem- 
perature of  nearly  106°  F.  six  hours  after  injection  of  5  milli- 
grammes of  tuberculin  in  a  case  of  uncomplicated  synovial 
tuberculosis  in  a  girl  18  years  of  age,  who  had  a  normal  tem- 
perature before  the  injection  was  made.  The  local  reaction  is 
prompt,  and  sets  in  within  twelve  hours  after  the  administration 
of  the  remedy,  and  consists  of  swelling,  increased  pain,  and 
tenderness, — in  fact,  the  substitution  of  a  brief  acute  attack  in 
place  of  the  chronic  inflammation. 


CHAPTER   III. 

BACILLUS  TUBERCULOSIS. 

THE  bacillus  tuberculosis,  bacillus  Kochii  or  tubercle  bacillus, 
is  one  of  the  smallest  of  the  known  bacilli.  In  length  it  is  about 
one-fourth  to  three-fourths  of  the  diameter  of  a  red  blood-cor- 
puscle. It  appears  in  the  tissues  and  cultures  in  the  shape  of 
very  thin  rods  from  two  to  eight  micro  millimetres  in  length,  and 
rounded  at  the  ends.  (Plate  I,  Fig.  1.) 

The  length  is  always  from  five  to  six  times  greater  than  its 
breadth.  In  cultures  the  bacillus  is  always  somewhat  shorter 
and  more  delicate  than  in  the  living  tissues.  The  largest  bacilli 
can  be  found  in  phthisical  sputa.  In  the  tissues  and  in  fresh 
cultures  the  bacilli  appear  as  nearly  straight  rods,  while  in  old 
cultures  and  in  the  expectoration  of  phthisical  patients  they  are 
often  curved,  and  sometimes  acutely  flexed.  As  a  rule,  they  are 
seen  under  the  microscope  as  isolated  rods;  only  seldom  are 
they  arranged  in  pairs,  and  when  this  is  the  case  the  two  rods 
form  an  obtuse  angle.  The  tubercle  bacillus  is  a  non-motile 
microbe,  and  consequently  possesses  no  power  of  locomotion, 
and  it  cannot  penetrate  on  the  tissues  without  assistance.  In 
old  tubercular  products  and  cultures  the  rods  do  not  stain  uni- 
formly ;  oval  spots  in  their  interior  do  not  take  up  the  staining 
material  and  impart  to  the  rods  a  chain-like  appearance. 

Koch  has  interpreted  these  light  spots  as  endogenous  spores. 
Sporulation  occurs  within  the  living  body  when  the  bacillus  is 
imbedded  in  a  soil  favorable  to  its  rapid  growth  and  reproduc- 
tion. The  staining  properties  of  the  tubercle  bacillus  are  of  a 
specific  and  peculiar  nature,  which  distinguish  this  microbe 
from  all  other  pathogenic  organisms.  Koch's  original  assertion 
that  the  bacillus  can  only  be  stained  with  alkaline  aniline  dyes, 
or  by  the  addition  of  aniline  oil,  carbonic  acid,  etc.,  has  not 
been  sustained  by  subsequent  researches,  as  this  microbe  can  be 
stained  with  an  aqueous  or  alcoholic  solution  of  aniline  dyes, 
(22) 


PLATE  I. 


FIG.  1. — TUBERCLE  BACILLI  CONTAINING  SPORES.    Zeiss  T\  0.4.     (K.  Koch.) 


FIG.  2. — TUBERCLE   BACILLI   FROM  A  TUBERCULAR   CAVITY.      CARBOL-FUCHSIN, 
NITRIC^  ACID,  METHYL-BLUE.    Zeiss  T^  0.4. 


BACILLUS   TUBERCULOSIS.  23 

although  not  as  intensive  or  brilliantly  as  with  the  more  com- 
plicated solutions.  In  reference  to  the  staining  process,  tubercle 
bacilli  differ  from  all  other  known  pathogenic  microbes,  in  that 
they  are  penetrated  very  slowly  by  the  aniline  dyes,  and  in  their 
specific  behavior  to  decolorizing  agents  like  mineral  acids  and 
alcohol.  Upon  what  this  differential  behavior  rests  is  as  yet 
unknown.  For  section-staining  Ehrlich's  method  is  the  best : — 

Saturated  alcoholic  solution  of  methyl  violet  or 

fuchsin,     ........  11  parts. 

Aniline  water, 100      " 

Absolute  alcohol, 10      " 

Sections  are  left  for  twelve  hours  in  this  solution.  Treat 
the  specimen  with  1 : 3  solution  of  nitric  acid  a  few  seconds. 
Wash  in  alcohol  (60  per  cent.)  for  a  few  minutes;  after  stain 
with  diluted  solution  of  vesuvin  or  methylene  blue  for  a  few 
minutes ;  wash  again  in  60-per-cent.  alcohol,  dehydrate  in  abso- 
lute alcohol,  clear  with  cedar-oil,  mount  in  Canada  balsam. 
Ziehl-Neelsen's  method  has  also  been  frequently  employed;  100 
grammes  of  distilled  water  are  mixed  with  5  grammes  of  crys- 
tallized carbolic  acid  and  1  gramme  of  fuchsin,  and  to  the 
filtered  solution  10  grammes  of  alcohol  are  added.  As  a  de- 
colorizing agent  a  5-per-cent.  solution  of  sulphuric  acid  is  used. 
The  remaining  technique  is  the  same  as  in  Ehrlich's  method. 
(Plate  I,  Fig.  2.) 

The  examination  of  fluids  for  tubercle  bacilli  can  be  done 
rapidly  and  very  satisfactorily  by  Gibbes'  method. 

Gfibbes'  Magenta  Solution. 

Magenta,  . 2  parts. 

Aniline  oil,       .        .        .        .        .        .        .  8      " 

Alcohol  (specific  gravity  0.830),     .        .        .        .  20      " 

Distilled  water, .  20      " 

Stain  cover-glass  preparation  in  this  solution  for  fifteen  or 
twenty  minutes;  wash  in  (1 :  3)  solution  of  nitric  acid  until  the 
color  is  removed;  rinse  in  distilled  water.  After  stain  with 
methylene  blue,  methyl  green,  iodine  green,  or  a  watery  solution 
of  crysoidin,  five  minutes ;  wash  in  distilled  water  until  no  more 


24  TUBERCULOSIS   OF    THE   BONES    AND    JOINTS. 

color  comes  away.  Transfer  to  absolute  alcohol  for  five 
minutes,  dry,  and  preserve  in  Canada  balsam.  Frankel's 
method  requires  only  four  minutes.  Aniline  water  with  7  per 
cent,  of  alcohol  is  boiled  in  a  test-tube  and  is  then  poured  in  a 
watch-glass  and  saturated  with  an  alcoholic  solution  of  fuchsin. 
This  staining  material  is  always  prepared  fresh,  and  from  it  the 
slide  preparation  is  dipped  into  a.  mixture  of  acid  with  methyl 
blue  (50  parts  distilled  water,  30  parts  alcohol,  20  parts  nitric 
acid,  methyl  blue  as  much  as  can  be  dissolved).  After  this,  as 
in  Ehrlich's  method,  wash  in  water  or  a  weak  acid  solution,  1 
per  cent,  acetic  acid,  50  per  cent,  alcohol;  examination  of 
specimen  in  water,  or,  after  drying  in  alcohol-flame,  mount  in 
Canada  balsam. 

The  best  culture  medium  of  the  tubercle  bacillus  is  solid 
sterilized  blood-serum  of  the  cow  or  sheep,  Avith  or  without  the 
addition  of  gelatin,  at  a  temperature  of  37°  to  38°  C.  (98.6°  to 
100.4°  F.).  The  bacillus  grows  very  slowly  and  only  between 
the  temperatures  of  30°  and  41°  C.  (86°  and  105.8°  F.).  In 
about  a  week  or  ten  days  the  culture  appears  as  little  whitish 
or  yellowish  scales  and  grains.  In  cultures  on  serum  ten  to 
fifteen  days  elapse  before  growth  can  be  detected  by  the  unaided 
eye.  (Plate  II,  Fig.  3.) 

The  bacillus  can  also  be  cultivated  in  a  glass  capsule  on 
blood-serum,  and  the  appearance  of  the  growth  studied  under 
the  microscope.  The  scales  or  pellicles  are  then  seen  to  be 
made  up  of  colonies  of  a  perfectly  characteristic  appearance. 
(Plate  III,  Fig.  4.) 

The  growth  ceases  after  three  or  four  weeks.  The  blood- 
serum  is  not  liquefied,  unless  putrefactive  bacteria  contaminate 
the  culture.  Besides  solidified  blood-serum,  the  only  substance 
on  which  the  tubercle  bacillus  can  be  cultivated  is  agar  (meat- 
infusion  peptone-agar),  and  in  fluid  blood-serum  and  bouillon. 
According  to  Nocard  and  Roux,  the  addition  of  glycerin  to  the 
proper  nutrient  media  favors  the  growth  of  the  bacillus.  The 
bacillus  of  tuberculosis  offers  a  somewhat  high  degree  of  resist- 


PLATE  II. 


FIG.  3. — VEGETATIONS  OF  TUBEKCLE  BACILLI   UPON  STERILIZED   BLOOD-SERUM, 
TWENTY-SIX  WEEKS  OLD.     Natural  Size.      (Baumgarten.) 


PLATE  III. 


FIG.  4. —  TUBERCLE  BACILLI.  COLONY  ON  SOLIDIFIED  BLOOD-SERUM, 
FOURTEEN  DAYS  OLD;  STAINED  WITH  CARBOL-FUCHSIN,  DECOLORIZED  WITH 
DILUTE  NITRIC  ACID.  X  100.  (Frankel  and  Pfeiffer.) 


BUKK  &  M^FEIRIOGE  UTH.  PH/L 


PLATE    IV. 


FIG.  5. — GLASS-SLIDE  PREPARATION  FROM  THE  TISSUE-JUICE  OF  A  FRESH 
INOCULATION  TUBERCLE.  EHRLICH'S  STAINING.  Zeiss,  homog.  immers.,  ^  0.4, 
magnified  about  1500  times.  (Baumgarten.) 


FIG.  6. — FROM  ENCYSTED  BRONCHIAL  GLANDS  IN  MILIARY  TUBERCULOSIS.    GIANT- 
CELL  WITH  RADIATING  ARRANGEMENT  OF  BACILLI.     700  diam.     (Koch.) 


BACILLUS   TUBERCULOSIS.  25 

ance  to  injurious  influences  from  without,  and  is  thus  able  to 
preserve  its  power  of  infection  under  circumstances  which  would 
prove  fatal  to  most  other  pathogenic  microbes.  It  can  bear 
temperatures  approaching  the  boiling-point,  though  it  is  soon 
destroyed  if  it  is  heated  in  a  thoroughly  moist  condition.  Schill 
and  Fischer  have  fixed  the  thermal  death-point  of  the  bacillus 
of  tuberculosis  at  212°  F.,  with  an  exposure  to  this  temperature 
of  four  minutes.  It  was  not  affected  by  drying  during  a  period 
of  186  days,  or  by  being  kept  in  putrefying  sputum  for  43  days. 
No  attempt  has  been  made  to  determine  precisely  how  far  these 
powers  of  endurance  are  confined  to  the  spores  or  belong  also 
to  the  vegetative  rods,  but  our  knowledge  of  the  life-history  of 
other  microbes  would  indicate  that  the  spores  possess  a  greater 
power  of  resistance  to  thermal  and  chemical  agents  than  the 
protoplasm  of  the  bacillus.  The  bacilli  and  spores  succumb 
more  readily  to  chemical  agents  than  heat.  Cavagnis,  Schill, 
and  Fischer  found  that  they  were  destroyed  in  a  3-per-cent. 
solution  of  carbolic  acid  in  20  hours.  Cavagnis  ascertained 
that  the  bacilli  in  tubercular  sputum  are  destroyed  in  a  1  to 
5000  solution  of  corrosive  sublimate  in  20  hours,  and  in  a 
stronger  solution  in  a  much  shorter  time. 

Experiments  and  clinical  observation  have  shown  that 
iodoform,  if  it  does  not  possess  the  power  to  destroy  the  bacilli 
and  their  spores,  at  least  exerts  a  potent  inhibitory  effect  on  the 
growth  in  the  tissues,  to  which  must  be  attributed  at  least  one 
of  its  therapeutic  actions  in  the  treatment  of  tubercular  affec- 
tions. In  the  tubercular  tissue  the  bacilli  are  found  within  and 
between  the  epithelioid  and  giant  cells.  (Plate  IV,  Fig.  5.) 

In  the  giant-cells  the  bacilli  occupy  the  periphery  of  the 
cell  whel'e  they  are  arranged  in  a  radiate  manner,  singly  or  in 
pairs.  (Plate  IV,  Fig.  6.) 

The  number  of  bacilli  diminishes  toward  the  centre  of  the 
cell  where  coagulation  necrosis  has  occurred.  The  bacillus  dis- 
appears in  old  tubercular  products,  caseous  material,  and  tuber- 
cular pus ,-  but  these  substances  retain  their  infectious  proper- 


26  TUBERCULOSIS   OP   THE   BONES   AND   JOINTS. 

ties,  owing  to  the  presence  of  living  spores,  which  remain 
indefinitely  in  an  active  condition  in  soils  in  which  the  bacillus 
cannot  thrive  and  grow.  It  is  on  this  account  that  in  active 
tubercular  foci  with  a  central  area  of  degeneration  the  bacilli 
are  found  in  greatest  number  toward  the  periphery  of  the 
inflammatory  product  within  and  between  the  living  cells. 


CHAPTER  IV. 

HISTOLOGY  OF  TUBERCLE. 

A  CORRECT  knowledge  of  the  minute  morbid  anatomy  of 
tubercular  disease  of  bones  and  joints  is  of  great  practical 
importance  at  the  present  time,  as  the  tendency  among  sur- 
geons now  is  to  limit  operative  procedures  to  removal  of  dis- 
eased tissue  only.  The  microbic  cause  of  the  tubercular 
inflammation  resides  within,  between,  and  in  the  immediate 
vicinity  of  the  cells  which  constitute  the  inflammatory  product, 
and  in  order  to  treat  successfully  a  tubercular  lesion  in  a  bone 
or  joint  by  direct  surgical  procedures  it  is  necessary  to  remove 
all  of  the  histological  elements  of  the  inflammatory  lesion  and 
the  product  of  cell  degeneration,  or  to  destroy  the  tubercle 
bacilli  by  antibacillary  agents.  A  primary  tubercle  is  an  aggre- 
gation of  cells,  the  product  of  a  minute  focus  of  inflammation, 
produced  by  the  presence  of  the  essential  cause  of  tuberculosis. 
The  primary  nodule  is  invisible  to  the  naked  eye,  and  when  it 
becomes  so  large  that  it  can  be  recognized  without  the  aid  of 
the  microscope  it  already  consists  of  a  confluence  of  a  number 
of  minute  microscopic  nodules.  For  a  long  time  great  confu- 
sion prevailed  in  regard  to  the  identity  or  non-identity  of 
caseous  foci  and  gray  or  miliary  tubercle.  Some  pathologists 
believed  these  formations  represented  the  product  of  distinct 
and  specific  types  of  inflammation,  while  others  regarded  them 
as  different  stages  of  the  same  process.  The  distinguished 
Laennec  entertained  the  latter  view.  This  author  described 
four  varieties  of  tubercle :  1 .  Miliary  tubercle,  where  the  visi- 
ble product  of  tubercular  inflammation  appears  in  the  form  of 
nodules  the  size  of  a  millet-seed,  of  a  grayish  color,  and  usually 
arranged  in  groups.  2.  Crude  tubercle,  where  the  miliary 
nodules  have  become  confluent  and  undergo  cheesy  degenera- 
tion. 3.  Granular  tubercle,  where  the  nodules  are  extremely 
small,  nearly  the  size  of  a  millet-seed,  aand  .scattered  uniformly 
through  a  whole  organ.  They  are  not  arranged  in  groups,  and 

(27) 


28  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

have  no  tendency  to  become  confluent.  In  the  centre  they 
become  transformed  into  yellow  tubercle.  4.  Encysted  tuber- 
cles, or  such  as  are  constituted  of  a  hard  mass  of  crude  tubercle 
in  the  centre,  surrounded  by  a  firm,  fibrous  capsule.  These 
varieties  only  represent  different  phases  of  the  same  process  and 
different  stages  of  inflammation  produced  by  the  same  cause. 

The  anatomico-pathological  basis  of  tubercle  was  created 
by  Virchow,  and  has  been  firmly  established  through  the  labori- 
ous researches  of  Langhans,  Wagner,  Klebs,  Schueppel,  Ilind- 
fleisch,  Koster,  Friedlander,  Fox,  Baumgarten,  and  many  others. 
The  specific-cell  theory  has  had  many  able  advocates  and  has 
been  the  subject  of  many  animated  discussions ;  but  it  has  at 
last  been  abandoned  as  fallacious  and  unscientific.  Lebert's 
tubercle-corpuscle  is  a  thing  of  the  past,  and  is  only  referred  to 
as  a  landmark  in  the  history  of  tuberculosis.  There  are  no 
specific  tubercle-cells.  Reinhart  showed  that  these  cells,  which 
were  regarded  by  Lebert  as  characteristic  and  pathognomonic 
of  tubercle,  could  be  found  in  all  products  of  chronic  inflamma- 
tion, and  their  presence  was  only  an  evidence  that  a  certain 
amount  of  inflammation  existed.  When  we  speak  of  a  tuber- 
cle we  mean  a  nodule  or  granule,  which  is  composed  of  leuco- 
cytes derived  from  the  capillary  vessels  damaged  by  the  bacillus 
of  tuberculosis,  or  new  cells  resulting  from  tissue-proliferation 
of  pre-existing  cells  acted  upon  by  the  same  cause.  The  dis- 
tinguishing anatomical  character  of  the  nodule  consists  not  in 
the  presence  of  any  particular  cell-elements,  but  in  the  peculiar 
arrangement  of  the  cell ;  and  this  feature  is  the  only  reliable 
anatomical  guide  in  making  a  diagnosis  by  the  use  of  the  micro- 
scope. The  product  of  tubercular  inflammation  occurs  either 
in  the  form  of  submiliary,  microscopic  granules,  visible  miliary 
nodules,  or  a  cheesy  deposit,  which  may  occupy  an  entire  organ, 
as  a  lymphatic  gland ;  or  large,  isolated  foci,  as  in  bone.  Every 
tubercular  product  commences  as  submiliary  nodules,  which, 
when  they  become  confluent,  are  transformed  into  visible,  gray, 
miliary  nodules,  which  again  coalesce  after  they  have  under- 


HISTOLOGY    OF    TUBERCLE.  29 

gone  caseous  degeneration  from  cheesy  masses,  which  may  be 
either  small  and  circumscribed  or  large  and  diffuse. 

Virchow  defines  a  tubercle  as  a  nodule  representing  a  hetero- 
geneous growth, — a  product  originally  necessarily  of  a  cellular  na- 
ture,— taking  its  starting-point  from  the  connective  tissue  or  from 
other  mesoblastic  structures,  as  marrow,  fat,  lymphoid  tissue,  or 
bone.  He  asserts  that  the  microscopic  or  submiliary  granule  con- 
tains all  the  essential  histological  elements  of  tubercle,  and,  by  ag- 
gregation, forms  the  ordinary  miliary  nodule  of  Laennec.  When 
the  nodules  become  confluent  they  may  form  masses  the  size  of 
a  walnut,  surrounded  by  a  common  zone  of  embryonal  tissue. 
The  yellow  tubercle — the  crude  tubercle  of  Laennec — is  a  more 
advanced  stage  of  the  gray,  the  histological  elements  of  the 
latter  having  undergone  caseation.  Tubercular  tissue  in  bone 
and  joints,  as  in  other  organs,  presents  itself  in  two  forms, — 
either  as  a  circumscribed  nodular  product  or  tubercular  infiltra- 
tion,— and  both  forms  are  often  seen  in  the  same  specimen.  In 
the  diffuse  variety  the  epithelioid  cells  are  not  collected  in  small 
masses,  but  they  are  scattered  irregularly»through  the  other  tis- 
sues. The  part  which  is  the  seat  of  this  infiltration  presents 
two  types,  namely,  granulation  tissue  or  young  fibrous  tissue. 
In  the  former  the  granulation  tissue  contains  numerous  epitheli- 
oid and  giant  cells.  This  condition  is  found  in  synovial  mem- 
branes, where  caseation  is  in  progress,  and  also  precedes  the 
formation  of  abscesses,  and  the  disease  always  manifests  pro- 
gressive tendencies.  The  fibrous  form  is  best  seen  in  caries, 
and  we  find  young  fibrous  tissue  infiltrated  with  epithelioid 
and  giant  cells,  and  is  characterized  by  a  lesser  tendency  to 
degeneration. 

Minute  Anatomy  of  Tubercle. — The  essential  histological 
elements  which  make  up  a  primary  tubercle-nodule  are:  (a) 
leucocytes ;  (6)  giant-cells ;  (c)  epithelioid  cells ;  (d)  reticulum. 

Leucocytes. — One  of  the  convincing  proofs  of  the  inflam- 
matory nature  of  tuberculosis  is  the  presence  of  leucocytes  in 
the  tubercular  nodule.  The  bacillus  of  tuberculosis  appears  to 


30 


TUBERCULOSIS   OF    THE   BONES   AND   JOINTS. 


exercise  only  a  mild  pathogenic  effect  on  the  capillary  wall,  and 
the  primary  inflammatory  product  is  always  scanty.  As  the 
colorless  corpuscle  can  only  escape  in  considerable  number 
through  inflamed  capillary  walls  which  have  undergone  altera- 
tion from  the  action  of  some  specific  microbic  cause,  it  4s  evi- 
dent that  its  migration  into  the  paravascular  tissues,  where  it 
forms  a  part  of  the  tubercular  product,  can  only  occur  after 
such  alteration  has  taken  place  from  the  action  of  the  bacillus 
upon  the  cement-substance  of  the  endothelial  lining  of  the 


FIG.  7.— PRIMARY  TUBERCLE,    x  350. 

a,  giant-cells ;  b,  epithelioid  cells;  c,  leucocytes. 

capillary  vessels.  The  leucocytes  invariably  undergo  degener- 
ative changes,  and  are  never  transformed  into  other  forms  of 
cells  found  in  the  tubercular  product. 

Although  constantly  present,  they  are  most  numerous  when 
the  process  is  acute.  The  leucocytes  are  most  numerous  in  the 
peripheral  zone  of  the  tubercle-nodule,  but  they  are  also  found 
between  the  epithelioid  and  giant  cells,  gaining  entrance  into  the 
interior  of  the  nodule  by  migration. 

Giant-Cells. — After  Virchow  had  repeatedly  called  atten- 


HISTOLOGY    OF    TUBERCLE. 


31 


tion  to  the  occurrence  of  giant-cells  in  tubercle,  Langhans 
("Ueber  Riesenzellen."  Virchow's  Archiv,  B.  xlii,  S.  382) 
made  the  histogenesis  and  structure  of  these  cells  the  sub- 
ject of  special  study.  He  found  them  almost  constantly  in 
recent  tubercle.  He  showed  that  while  their  morphological 
characters  vary  greatly  they  resemble  each  other,  in  that  they 
always  contain  numerous  nuclei  which  are  arranged  radiate 
toward  the  centre  of  the  cells  in  their  periphery,  and,  further, 
that  many  of  them  are  surrounded  by  a  granular,  striped,  often 


D 


FIG.  8.— GIANT-CELL  FROM  CENTRE  OF  TUBERCLE  OF  LUNG.    X  450. 
(Hamilton.] 

A,  granular  protoplasmic  centre  ;  B,  peripheral  more-formed  part ;  C,  crescent  of  nuclei ;  D  D,  endothelial 
cells ;  £  E,  two  vacuoles  within  the  giant-cell,  or  are  arranged  in  a  crescent  at  one  end. 

very  thick  envelope.  Besides  these  large  cells  with  homo- 
geneous envelopes,  lie  described  many  intermediate  forms  be- 
tween these  and  cells  with  a  complete  capsule.  He  believes 
that  giant-cells  are  genetically  different  things,  as  they  originate 
from  small  multmuclear  cells,  others  from  stellate  cellular  ele- 
ments; while  those  with  cell-mantels  are  produced  by  conflu- 
ence of  cells  which  retain  their  nuclei.  The  giant-cells,  or,  as 
Klebs  calls  them,  macrocytes,  are  finely  granular,  and  contain 
multiple  nuclei,  which  usually  occupy  the  periphery  of  the  cell. 


32 


TUBERCULOSIS    OF    THE    BONES    AND    JOINTS. 


The  giant-cells  are  the  most  striking  histological  elements 
in  a  tubercle,  but  as  they  are  not  constantly  found  they  are  not 
essential.  The  giant-cell  found  in  tubercular  tissue  has  its  pro- 
totype in  normal  tissue.  The  giant-cells  were  first  discovered 
in  normal  tissue  (marrow  of  bone)  by  Robin,  who  called  them 
myelophiques.  Wegner  ("  Myeloplaxen  und  Knochenresorp- 
tionszellen."  Virchow's  Archiv,  B.  Ivi,  S.  523),  as  the  result 
of  his  own  careful  investigations  concerning  resorption  of  bone 
in  normal  and  pathological  conditions,  maintains  that  the  giant- 
cells — or  osteoclasts — which  perform  this  function  are  not  pro- 
duced by  the  bone-cells.  He 
has  traced  them  to  small  cells 
of  the  blood-vessels,  which,  at 
first,  contain  only  one  nucleus, 
but  later  increase  in  size,  and  at 
the  same  time  become  multinu- 
clear.  He  has  found  such  cells 
always  in  the  immediate  vicinity 
of  capillary  vessels  and  small 
arteries  and  veins.  In  a  normal 
condition  they  are  constantly 


FIG.  9.— A  GIANT-CELL  FROM  THE  LUNG 
IN  A  CASE  OF  CHKONIC  PHTHISIS,  SHOW- 
ING THE  LARGE  NUMBER  OF  NUCLI 
EIGHT  NUCL.EOLI.    X  400.    (Green.) 


found  in  bone  and  the  placenta. 


ING  THE  LARGE  NUMBER  OF  NUCLEI  WITH    They  are  also  found  occasionally 


in  fat-tissue,  especially  in  cases 
of  rapid  emaciation.  Kundrat  has  found  them  in  inflamed  serous 
membranes,  and  Strieker  and  Heitzmann  in  the  inflamed  cornea. 
They  are  always  found  around  foreign  bodies,  becoming  encysted 
in  the  tissues.  Friedlander  found  them  present  in  the  alveoli 
of  the  lungs  in  cases  of  chronic  pneumonia. 

Heubner  found  giant-cells  in  endarteritis,  Baumgarten  in 
gummata,  Buhl  and  Jacobson  in  granulating  wounds,  and 
finally  Johne  and  Pflug  in  actinomycotic  foci.  The  giant-cells 
found  in  inflammatory  products  under  such  variable  circum- 
stances resemble  the  large  multinuclear  cells  found  in  some  forms 
of  sarcoma,  and  appear  to  be  simply  certain  embryonal  cells 


HISTOLOGY   OF   TUBERCLE.  33 

which  have  outgrown  others  by  taking  up  a  greater  amount  of 
nourishment  in  the  shape  of  leucocytes  which  have  undergone 
fragmentation.  Watson  Cheyne  believes  that  they  are  derived 
from  epithelioid  cells,  either  by  hypernutrition  or  coalescence  of 
neighboring  cells.  The  histological  source  of  these  cells  has 
been  traced  to  epithelial  cells  by  Zielonko  and  Weigert;  to 
endothelial  cells  by  Kundrat,  Klebs,  Herrenkohl,  and  Zielonko ; 
to  connective  tissue  or  endothelial  cells  by  Virchow,  Fleming, 
and  Ziegler.  Sclmeppel  and  Rindfleisch  believe  that  they 
invariably  originate  within  blood-vessels  or  lymphatics,  where 
these  authors  regard  them  as  the  first  step  toward  the  develop- 
ment of  tubercle-nodules.  Ziegler  claims  to  have  seen  giant- 
cells  develop  from  white  blood-corpuscles.  Herig,  Aufrecht, 
Woodward,  Schueller,  and  Treves  are  of  the  opinion  that  what 
appear  as  giant-cells  in  tubercular  tissue  are  not  cells,  but  only 
represent  spaces  which  correspond  to  transverse  sections  of 
lymphatic  vessels,  the  portion  of  the  cell  representing  the  proto- 
plasm being  the  coagulated  lymph  within  these  vessels,  and 
what  appear  as  nuclei  being  enlarged,  swollen,  endothelial  cells. 
Each  tubercle  usually  contains  one  giant-cell  in  its  centre.  The 
periphery  of  the  giant-cell  presents  projections  or  protoplasmic 
strings  uniting  with  the  epithelioid  cells,  or  ramify  among  these 
cells.  Young  giant-cells  possess  amoeboid  movements,  and  by 
virtue  of  these  they  are  capable  of  taking  up  in  their  proto- 
plasm fine  particles — such  as  microbes,  pigment  material,  and 
blood-corpuscles — which  have  undergone  fragmentation. 

RufFer  ("  Notes  on  the  Destruction  of  Micro-organisms  by 
Amoeboid  Cells."  British  Medical  Journal,  August  30,  1890) 
has  lately  discovered,  quite  accidentally,  one  fact  which  illus- 
trates the  destructive  function  of  giant-cells.  In  the  spleen  of 
many  animals,  more  especially  of  guinea-pigs,  the  non-nucleated 
epithelioid  cells  often  contain  a  quantity  of  pigment,  which  is 
really  the  remainder  of  red  corpuscles,  destroyed  in  the  interior 
of  these  cells.  RufFer  has  shown  that  the  number  of  these 
cells  is  greatly  increased  in  certain  infective  diseases, — that  is, 


34  TUBERCULOSIS   OF   THE   BONES  AND   JOINTS. 

quarter-evil.  In  the  spleen  of  tubercular  guinea-pigs,  in  which 
the  tubercle  has  invaded  that  organ,  the  destruction  of  red 
blood-corpuscles  in  the  macrophages  of  the  spleen  is  an 
extremely  active  one ;  but — and  this  is  the  most  interesting 
point — the  giant-cells  of  tubercle  take  an  active  part  in  this 
process,  and  the  same  author  has  demonstrated  in  their  interior 
blood-pigment  and  debris  of  partially  digested  leucocytes, — a 
further  proof  that  giant-cells  are  amoeboid,  and,  like  other 
amoeboid  structures,  have  the  power  of  taking  into  their  interior 
and  digesting  red  blood-corpuscles,  leucocytes,  and  micro-organ- 
isms. The  giant-cells  in  tubercular  tissue  are  nothing  more  nor 
less  than  hyperplastic  epithelioid  cells,  and,  consequently,  are 
derived  from  the  same  histological  source  as  these. 

Epithelioid  Cells. — Cells  intermediate  in  size  between  the 
giant-cells  and  the  leucocytes  are  found  in  every  tubercle-nodule 
in  which  cell  identity  has  not  been  destroyed  by  caseation  and 
liquefaction  of  the  tubercular  product.  These  cells  were  first 
described  by  Bindfleisch,  and  were  called  by  him  epithelioid 
cells,  from  their  structural  resemblance  to  epithelial  cells. 
Klebs  calls  them  platijcytes.  They  are  about  two  or  three 
times  larger  than  a  white  blood-corpuscle,  and  in  shape  they 
are  round,  or  somewhat  elongated.  (Fig.  5.)  In  structure 
they  are  finely  granular,  and  contain  one  large  nucleus  and  often 
a  number  of  small  nuclei.  They  form  the  bulk  of  all  recent 
nodules,  are  scattered  between  the  giant-cells,  and  are  often 
arranged  in  layers  around  them.  Baumgarten  has  found  that 
in  tubercular  tissue  karyokinesis  only  occurs  in  the  epithelioid 
cells  and  in  the  cells  from  which  they  are  derived,  and  hence 
he  comes  to  the  conclusion  that  they  are  the  essential  histolog- 
ical element  of  tubercle.  The  histological  source  of  these  cells 
was  supposed  to  be  the  leucocyte  by  Schueppel,  Ziegler,  and 
Treves ;  the  endothelial  cells  of  the  lymph-spaces  by  Aufrecht, 
Hering,  and  Woodward ;  the  endothelial  cells  of  the  blood- 
vessels and  lymphatics,  or  connective-tissue  cells,  by  Bindfleisch. 
and  many  of  the  modern  authors.  The  histological  source  of 


HISTOLOGY   OF    TUBERCLE. 


35 


epithelioid  cells  is  manifold.  In  the  synovial  membrane  they 
are  derived  most  often  from  the  endothelial  cells  of  blood- 
vessels, and  in  bone  from  the  medullary  tissue. 

The  epithelioid  cells  are  the  embryonal  cells,  the  product  of 
proliferation  from  any  of  the  fixed  tissue-cells  in  a  tubercular 
inflammation,  and  they  remain  as  such  until  they  are  destroyed 
by  degenerative  changes  from  the  continued  action  upon  them 
of  the  bacillus  of  tuberculosis  or  its  ptomaines,  or  until  some  of 
them  become,  by  hypernutrition,  giant-cells  ;  or,  on  cessation  of 


FIG.  10. — MtTLTINUCLEATED  AND  BRANCHED  (JELLS  FROM  A  FINE,  GRAY,  MlLIARY 

TUBERCLE  OF  THE  LUNG,  IN  A  CASE  OF  ACUTE  TUBERCULOSIS.    X200.    (Green.) 

Wide  meshes  are  seen  in  the  immediate  vicinity  of  the  cells,  inclosing  a  few  lymphoid  elements. 
The  branched  processes  are  directly  continuous  with  the  adenoid  reticulum  of  the  tubercle. 

the  primary  cause,  they  are  transformed  into  tissue  of  greater 
durability. 

Reticidum. — Schueppel  first  called  attention  to  the  .reticu- 
lated structure  of  tubercle  by  his  description  of  the  reticular 
arrangement  within  tubercles  of  lymphatic  glands.  The  reticu- 
lum, according  to  most  authors,  consists  of  the  pre-existing 
connective  tissue  pushed  asunder  by  the  new  cells.  According 
to  Wagner,  Schueppel,  Brodowski,  Thaon,  and  Ziegler,  it  is 
made  up  of  protoplasm.  Buhl  taught  that  the  giant  and  epi- 


36 


TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 


thelioid  cells  secrete  a  substance  at  their  periphery,  which,  on 
becoming  firm,  is  formed  into  a  structure  resembling  connective 
tissue.  According  to  his  researches,  only  the  marginal  zone  is 
supplied  with  loose,  ready-formed  connective  tissue  of  the  organ. 
Wahlberg  maintained  that  the  principal  reticulum  consists 
of  protoplasm, which  is  traversed  by  a  net-work  of  connective 


A- — -/- 


—  D 


-A 


C  -•": 


C 


FIG.  11.— FULLY-DEVELOPED  RETICULAR  TUBERCLE  OF  LUNG.    X450.    (Hamilton.) 

A,  A,  A,  giant-cells ;  B.  vacuoles  in  one  of  them ;  C,  peripheral  capsule  of  fibrous  tissue ;  D.  reticu- 
Inm  of  the  tubercle;  E.  large,  endothelium-like  cells  lying  on  the  reticulum  and  within  its  meshes:  F, 
smaller  "  lymphoid  "  cells  occupying  the  same  situation ;  G,  peripheral,  fibrous-looking  border  of  the 
giant-cells. 

tissue.  The  reticulum  is  always  more  marked  in  the  periphery 
of  the  tubercle-nodule,  where,  from  pressure,  it  is  condensed 
into  a  fibrous  capsule.  Watson  Cheyne  was  never  able  to  dis- 
tinguish a  reticulum  in  tubercle,  and  he  believes  what  has  been 
regarded  as  such  has  been  processes  of  giant-cell,  bands  of  con- 
nective tissue,  and  diffraction  appearances  due  to  imperfect  illu- 


PLATE  V. 


FIG.  12. — CIRCUMSCRIBED  TUBERCLE  OF  IRIS,  CONSISTING  OF  EPITHELIOID 
CELLS.  KARYOKINETIC  CHANGES  OBSERVED  ONLY  IN  A  FEW  OF  THE  PERIPHERAL 
CELLS.  DOUBLE  STAINING.  X  950.  (Baumgarten.) 


HISTOLOGY   OF   TUBERCLE.  37 

mination.  Anything  like  a  reticulated  frame-work  in  tubercle 
can,  of  course,  only  be  found  during  the  very  earliest  stage  of 
the  tubercular  inflammation,  before  the  pre-existing  connective- 
tissue  spaces  have  become  obscured  by  the  inflammatory  exuda- 
tion. In  the  centre  of  the  nodule  the  connective-tissue  frame-work 
soon  disappears,  as  it  takes  an  active  part  in  the  inflammatory 
process  and  becomes  transformed  into  epithelioid  cells,  while 
toward  the  periphery  it  remains  for  a  longer  time. 

Arrangement  of  Cells  in  a  Recent  Tubercle-Nodule. — The 
earliest  evidences  of  the  formation  of  a  tubercle-nodule,  as  wit- 
nessed under  the  microscope,  is  the  appearance  of  small  cells, 
which  resemble  ordinary  embryonal  cells,  which  are  the  product 
of  tissue-proliferation  from  a  mesoblastic  matrix — usually  the 
connective  tissue — and  its  embryological  and  histological  proto- 
type,— the  endothelial  cells  of  blood-vessels  and  lymphatics. 
(Plate  V,  Fig.  12.) 

From  these  cells  the  epithelioid  and  giant  cells  are,  later, 
developed.  Some  of  the  central  cells,  by  appropriation  of  a 
superabundance  of  food  furnished  by  leucocytes  in  a  state  of 
fragmentation,  become  hyperplastic,  and  are  transformed  into 
giant-cells ;  these  occupy  the  centre  of  the  nodule.  Around 
these  cells  the  smaller  or  epithelioid  cells  arrange  themselves, 
and  between  them  and  in  the  periphery  of  the  nodule  are.  found 
the  smallest  cells, — the  leucocytes. 

Gaule  and  Tizzoni  distinguish  three  zones  in  a  tubercle : 
(1)  an  external,  composed  of  small  round-cells;  (2)  a  lesser, 
epithelial,  or  middle  zone,  'containing  the  reticulum ;  (3)  a  cen- 
tral space  containing  a  giant-cell.  The  structure  of  a  tubercle 
is  not  always  typical,  and  hence  the  division  into  zones  is  based 
more  on  theoretical  grounds  than  actual  observation.  The  giant- 
cell  is  not  an  essential  histological  element  of  tubercle,  but  an 
accidental  product.  In  some  tubercles  giant-cells  cannot  be 
found,  while  in  others  they  are  numerous.  Giant-cells  can  only 
develop  from  epithelioid  cells  if  the  local  conditions  are  favor- 
able for  hypernutrition ;  that  is,  if  the  leucocytes,  in  a  condition 


38  TUBERCULOSIS   OP   THE   BONES   AND   JOINTS. 

of  fragmentation,  are  within  their  grasp.  If  they  are  present 
they  always  mark  the  location  of  the  starting-point  of  the 
tubercular  infection,  as  only  the  older  leucocytes  undergo  this 
change.  The  number  and  size  of  the  epithelioid  cells  are  also 
subject  to  great  variation,  and  are  further  modified  by  the  nutri- 
tive conditions  within  and  in  the  immediate  vicinity  of  the  nod- 
ule. If  cell-proliferation  is  active  the  epithelioid  cells  appear 
densely  packed  in  the  reticulum,  nutrition  is  greatly  impaired, 
and  the  new  cells  undergo  degenerative  changes  before  they 
attain  their  average  size.  The  leucocytes  are  scattered  among 
the  giant  and  epithelioid  cells,  and  as  they  reach  the  part 
through  the  inflamed  wall  of  the  capillaries  in  the  immediate 
vicinity  they  are  most  numerous  in  the  periphery  of  the  nodule 
and  along  the  course  of  the  affected  vessels.  TJie  product  of 
tubercular  inflammation  acts  as  an  irritant,  and  produces  an 
inflammation  of  a  chronic  type  in  its  immediate  vicinity. 

Blood- Supply  of  Tubercle-Nodule. — If  tubercle  is  primarily 
an  endovascular  product,  as  is  so  often  the  case,  its  outer  wall 
is  fibrous,  composed  of  remnants  of  blood-vessels,  in  the  interior 
of  which  the  essential  tubercular  product  can  be  seen  and 
studied.  The  blood-vessel,  at  a  point  corresponding  with  the 
tubercle,  becomes  obliterated  by  a  tubercular  thrombus  from  the 
very  beginning,  and  the  tubercular  tissue  is  cut  off  from  further 
blood-supply,  as  new  blood-vessels  never  form  in  tubercle.  If 
the  tubercle-nodule  originates  in  the  paravascular  spaces,  the 
cells  which  accumulate  push  the  vessels  apart  and  form  an  avas- 
cular  inflammatory  product  between  them.  If  a  number  of 
tubercles  become  confluent,  the  capillary  vessels  between  them 
are  blocked  and  are  converted  into  tubercular  tissue,  thus  cut- 
ting off  permanently  the  blood-supply  to  the  infected  area. 
Some  of  the  old  authors  were  familiar  with  the  defective  blood- 
supply  of  tubercle.  Mr.  Stafford  ("  A  Treatise  on  the  Injuries, 
the  Diseases,  and  the  Distortions  of  the  Spine,"  p.  151.  London, 
1832);  in  speaking  of  scrofulous  affections  of  the  vertebrae,  in 
reference  to  the  blood-vessels  in  and  around  the  foci,  says  :  "  If 


HISTOLOGY   OF   TUBERCLE.  39 

the  bone,  as  may  be  seen  in  some  preparations  in  St.  Bartholo- 
mew's Museum,  be  injected  with  subtle  injection  in  the  early 
stage  of  the  disease,  before  caseous  matter  has  begun  to  accu- 
mulate, the  vessels  are  seen  to  ramify  freely  through  the 
cancelli ;  but  if  the  injection  be  made  when  the  cancellous 
structure  has  become  loaded  with  this  matter,  there  is  still  to 
be  seen  a  degree  of  vascularity  at  the  line  of  demarcation 
between  the  disease  and  the  sound  parts,  though  the  injection 
has  failed  to  enter  the  newly-formed  matter.  From  this,  we  may 
infer  that  this  deposition  is  like  pus, — a  mere  unorganized 
secretion."  The  absolute  ischcemia  of  the  tubercular  product  is 
one  of  the  conditions  which  determines  speedy  death  of  the  cel- 
lular elements,  coagulation  necrosis,  caseation,  and  liquefaction 
of  the  dead  material. 

Distribution  of  Tubercle  Bacilli  in  Nodule. — The  distribu- 
tion of  bacilli  in  tubercular  tissue  is  peculiar, — the  bacilli  are 
either  within  or  between  the  epithelioid  cells,  while  they  are 
not  found  beyond  the  inflammatory  zone.  In  the  epithelioid 
cells  they  are  usually  found  near  or  within  the  nucleus.  The 
disposition  of  bacilli  is  seen  in  the  tubercle-nodule  and  in  the 
tubercular  infiltration.  The  bacilli  can  be  found  best  by  first 
locating,  under  a  low  power,  tracts  of  epithelioid  cells.  If 
giant-cells  are  present,  bacilli  can  be  found  in  their  interior  in 
largest  number.  They  are  found  most  numerous  among  the 
peripheral  zone  of  nuclei,  and  arranged  in  such  a  manner  that 
the  long  axis  radiates  from  the  centre  of  the  cell.  Some  of  the 
bacilli  are  distributed  irregularly  through  the  intercellular 
spaces,  isolated  or  in  little  groups.  (Fig.  6.) 

As  degeneration  of  cells  takes  place  the  number  of  bacilli 
is  diminished,  and  they  either  cannot  be  found  at  all  or  an 
isolated  bacillus  can  be  detected  here  and  there,  on  most  careful 
examination.  Even  in  cases  where  no  bacilli  can  be  found  in 
the  cheesy  material  or  tubercular  pus,  these  substances  retain 
their  infective  properties,  as  numerous  inoculation  experiments 
have  shown, — a  proof  that  they  still  contain  the  bacilli,  which, 


40  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

perhaps,  are  refractory  to  the  staining  process,  or  the  bacilli 
have  disappeared,  or,  what  is  more  probable,  spores  have 
remained,  and  the  propagation  of  tile  disease  is  due  to  their 
presence. 

Groioth  of  the  Tubercle- Nodules. — The  typical  tubercle- 
nodule  is  microscopical  in  size.  The  growth  of  the  swelling 
depends  on  the  formation  of  new  tissue,  migration  of  leucocytes, 
and  confluence  of  nodules  into  larger  masses.  The  bacillus  of 
tuberculosis,  when  brought  in  contact  with  fixed  tissue-cells 
susceptible  to  its  pathogenic  action,  incites  tissue-proliferation, 
which  always  takes  place  by  karyokinesis.  Baumgarten's 
investigations  leave  no  doubt  that  epithelioid  cells  constitute  the 
entire  mass  of  the  forming  tubercle.  (Fig.  12.)  He  has  also 
observed  karyokinetic  figures  in  tubercular  tissue  in  cells  derived 
from  the  connective  tissue,  endothelia,  and  epithelia.  Each 
tubercle-nodule  increases  in  size  by  the  growth  of  new  cells 
from  pre-existing  tissue,  and,  as  the  primary  cause — the  bacillus 
of  tuberculosis — multiplies  in  the  tissues,  bacilli  are  conveyed 
into  the  surrounding  tissues  by  leucocytes  or  the  plasma-current, 
and  new  centres  for  tubercle  formation  are  established,  which, 
later,  become  confluent,  forming  masses  of  considerable  size, 
the  numerous  foci  of  caseation  corresponding  to  the  centres  of 
so  many  nodules.  The  growth  of  tubercle  is  favored  by  local 
and  general  conditions,  which  diminish  tissue-resistance,  while 
retardation  takes  place,  in  consequence  of  degenerative  changes 
in  the  cells  of  which  it  is  composed,  or,  if  the  cells  are  con* 
verted  into  tissue  of  a  higher  type,  from  disappearance  or  sus- 
pension of  activity  of  the  primary  cause.  The  anatomico- 
pathological  conditions  which  characterize  tubercle  put  a  limit 
to  its  growth,  and  further  increase  in  size  of  the  swelling  takes 
place  by  confluence  and  the  formation  of  new  centres  of  infection 
in  a  peripheral  direction. 


CHAPTER  V. 

HlSTOGENESIS   OF   TUBERCLE. 

THE  histological  source  of  the  inflammatory  product  was 
determined  nearly  fifty  years  ago  by  Virchow,  who  traced  the 
cell-proliferation  to  the  connective-tissue  cells.  Histological 
researches  since  that  time  have  added  but  little  to  our  knowl- 
edge of  the  histogenesis  of  tubercle.  The  connective  tissue  is  the 
principal  histological  source  of  the  cellular  elements  of  the 
tubercular  product,  irrespective  of  the  anatomical  location  of  the 
inflammation.  It  appears  that  the  bacillus  of  tuberculosis  exer- 
cises a  special  predilection  for  the  connective-tissue  cells.  While 
the  connective-tissue  proliferation  furnishes  the  bulk  of  the 
inflammatory  product  in  every  tubercle-nodule,  in  whatever 
part  or  organ  this  may  be  found,  it  is  now  generally  conceded 
that  the  pathogenic  action  of  the  tubercle  bacillus  is  not  limited 
to  the  connective-tissue  cell  alone,  but  that  other  mesoblastic 
tissues  are  affected  in  a  similar  manner,  and  contribute  to  a 
lesser  extent  to  the  building  up  of  the  tubercle-nodule.  Endo- 
thelial  cells  and  lymphoid  structures  in  different  organs  not 
infrequently  are  the  primary  seat  of  the  tubercular  inflammation, 
and,  when  excited  to  tissue-proliferation  by  the  presence  of 
tubercle  bacilli,  furnish  the  first  material  in  the  construction  of 
the  tubercle-nodule.  Bastian  observed  tubercle-nodules  upon 
the  small  vessels  in  cases  of  basilar  meningitis,  but  refers  their 
origin  not  to  proliferation  of  the  nuclei  of  the  endothelial  lining 
of  the  vessels,  but  to  new  cells  springing  from  the  endothelial 
cells  of  the  paravascular  lymphatic  sheaths  which  surround  the 
vessels  of  the  meninges  of  the  brain.  Knauff  demonstrated  the 
lymphoid  character  of  the  adventitia  by  examining  the  capillary 
vessels  of  the  visceral  pleura  in  dogs  which  had  been  exposed 
for  a  long  time  to  an  atmosphere  impregnated  with  coal-dust. 
He  found  the  pigment-granules  lodged  in  small  masses  close  to 
the  walls  of  small  arteries  and  veins.  Examining  the  same 
vessels  in  other  dogs  not  thus  treated,  he  found,  upon  the  outer 

(41) 


42 


TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 


surface  of  the  adventitia,  opaque,  whitish-gray  nodules,  sur- 
rounded by  round  and  oval  cells  containing  nuclei ;  also,  lymph- 
corpuscles.  The  same  structures,  which  he  named  lymph- 
nodules,  are  also  found  around  the  same  vessels  of  the  pleura  in 
man,  and  Knauff  looks  upon  these  lymphoid  structures  as  the 
starting-point  of  tubercular  inflammation.  Klebs  maintains  that 
the  endothelial  cells  of  lymphatic  vessels  are  the  most  frequent 
location  for  the  formation  of  the  primary  tubercle-nodule.  He 
observed  that  in  cases  of  tubercular  ulceration  of  the  intestines 
the  peritoneum  is  reached  through  the  lymphatic  vessels. 


FIG.  13.— MILIARY  TUBERCLE  IN  THE  PIA  MATER,    x  100.    (Cm-nil  and  Ranvier.) 

The  dotted  line  indicates  the  original  size  of  the  tubercular  nodule ;  A,  the  lymphatic  sheath  ;  V,  the 
blood-vessel ;  F,  proliferation  of  elements  within  the  sheath. 

Silver-stained  preparations  of  inoculation-tuberculosis  in  rabbits 
showed  that  the  most  recent  products  occurred  in  the  interior  of 
the  lymphatic  vessels  at  points  of  intersection.  In  some  places 
the  nodules  extended  into  the  tissues  between  the  lymphatic 
channels,  but  their  centre  always  corresponded  to  the  location 
of  a  lymphatic  vessel.  At  some  points  the  nodules  were  seen 
to  branch  out,  but  these  projections,  in  reality,  were  within  the 
lymphatic  vessels,  as  the  net-work  of  lymphatic  endothelia  could 
be  seen  above  and  underneath  the  tubercular  product.  Toward 
the  centre  of  the  nodule  no  endothelial  cells  could  be  distin- 


HISTOGENESIS   OF   TUBERCLE.  43 

guished,  and  this  fact  led  him  to  the  belief  that  the  endothelial 
cells  are  directly  concerned  in  the  production  of  the  new  tissue. 
In  the  mesentery  he  saw  the  tubercles  adhere  to  the  outer  wall 
of  the  capillary  vessels,  and,  as  the  spindle-shaped  cells  of  the 
outer  coat  appeared  to  be  pushed  apart  by  the  new  tissue,  he 
regards  the  adventitia  as  a  genuine  lymphoid  structure.  Rind- 
fleisch  traces  the  beginning  of  the  process  in  miliary  tuberculosis 
of  the  lungs  to  a  proliferation  of  the  endothelia  and  the  external 
connective-tissue  layer  of  the  capillary  lymphatic  vessels.  Manz 
studied  the  development  of  tubercle  in  the  choroid  in  patients 
suffering  from  general  miliary  tuberculosis.  So  constantly  does 
this  disease  show  itself  in  this  structure  that  von  Graefe,  Cohn- 
heim,  Frankel,  and  Bouchut  recommend  ophthalmoscopic  exam- 
ination as  a  diagnostic  measure  in  cases  of  suspected  general 
tuberculosis.  Manz  traces  the  commencement  of  the  disease  in 
the  choroid  to  cell-proliferation  in  the  tunica  adventitia  of  the 
small  vessels.  The  process  is,  however,  not  limited  to  this 
structure ;  the  non-pigmented  stroma-cells  may  also  assist  in 
furnishing  material  for  the  new  product.  Bart,  on  the  other 
hand,  asserts  that  the  vessels,  in  cases  of  tuberculosis  of  the 
choroid,  are  not  primarily  affected;  according  to  his  observation, 
the  process  depends  exclusively  on  a  degeneration  of  the  stroma- 
cells,  as  the  remaining  tissue  did  not  appear  to  be  affected. 

Cohnheim,  Ziegler,  and  others  maintain  that  the  leucocytes 
furnish  most  of  the  material  in  the  building  up  of  the  tubercle- 
nodule.  This  idea  is  no  longer  tenable,  as  the  tubercle  bacillus, 
when  brought  in  contact  with  fixed  tissue-cells,  is  known  to 
cause  active  cell-proliferation,  while  it  does  not  produce  a 
sufficient  alteration  in  the  walls  of  blood-vessels  to  enable  free 
cell-migration  to  take  place.  At  the  last  meeting  of  the  Inter- 
national Medical  Congress.  Ziegler  announced  that  he  had 
changed  his  ideas  in  reference  to  the  function  of  leucocytes,  and 
that  he  is  now  a  firm  believer  in  the  origin  of  inflammatory 
tissue  from  pre-existing  fixed  tissue-cells.  As  a  constant  patho- 
logical condition,  we  also  find,  in  every  tubercle-nodule,  early 


44  TUBERCULOSIS   OP   THE   BONES   AND   JOINTS. 

disappearance  of  most,  if  not  of  all,  of  the  capillaries, — a  con- 
dition unfavorable  to  cell-migration.  The  foundation  for  every 
tubercle-nodule  is  laid  by  cells  derived  from  the  fixed  tissue- 
cells,  the  presence  and  number  of  leucocytes  being  accidental, 
depending  upon  the  number  of  capillary  vessels  within  and  in 
the  immediate  vicinity  of  the  nodule,  and  the  intensity  of 
alteration  of  their  walls,  induced  by  the  irritation  caused  by 
the  presence  of  tubercle  bacilli  and  the  inflammatory  product 
furnished  by  the  fixed  tissue-cells.  In  bone,  the  medullary 
tissue,  being  a  lymphoid  structure,  is  acted  upon  by  the  tubercle 
bacilli,  and  furnishes  the  corpuscular  elements  of  the  inflamma- 
tory product,  if  the  process  is  extra-vascular,  while  the  endothe- 
lial  cells  and  connective  tissue  of  the  blood-vessels  are  the  struc- 
tures first  acted  upon  in  tubercles  of  this  structure  of  endovascular 
origin.  In  primary  tuberculosis  of  joints  the  synovial  membrane 
is  first  affected,  and  the  process  extends  from  here  to  the  subjacent 
cartilage  and  bone.  Experiments  on  animals,  as  well  as  micro- 
scopical examinations  of  pathological  specimens,  have  sufficiently 
demonstrated  the  fact  that  the  tubercle-nodule  in  bones  and 
joints,  as  well  as  in  other  organs,  is  nothing  more  nor  less  than 
a  circumscribed  inflammatory  product,  the  histological  elements 
of  which  are  composed,  for  the  most  part,  of  new  tissue,  formed 
by  proliferation  of  fixed  tissue-cells,  which  have  been  acted 
upon  by  the  bacillus  of  tuberculosis,  or  its  ptomaines.  The 
specific  pathogenic  effect  of  the  bacillus  consists  in  its  power  to 
cause  a  chronic  inflammation  of  the  tissues  with  which  it  has 
been  brought  in  contact.  The  tissues  primarily  affected  are  the 
cells  which  are  nearest  the  essential  microbic  cause,  irrespective 
of  their  embryological  origin,  their  histological  structure,  or 
physiological  function.  The  mesoblastic  tissues  are  the  primary 
starting-point  of  the  tubercular  process,  in  the  majority  of  cases, 
for  the  reason  that  it  is  Jiere  that  localization  of  the  tubercle 
bacillus  takes  place  most  frequently.  In  cases  of  inoculation- 
tuberculosis,  the  primary  nodule  develops  at  the  point  of  inser- 
tion of  the  virus  from  connective-tissue  proliferation,  and  from 


HISTOGENESIS   OF   TUBERCLE.  45 

here  the  bacilli  enter  the  lymphatic  channels,  and  the  secondary 
nodules  are  composed  of  cells  derived  from  the  endothelial, 
lymphoid,  and  connective-tissue  cells  which  compose  these 
structures.  If  the  bacilli  are  injected  in  sufficient  quantity 
directly  into  the  circulation,  or  gain  entrance  into  the  blood- 
current  from  some  tubercular  focus,  they  become  implanted 
upon  the  wall  of  distant  capillary  vessels,  and  the  nodule  which 
forms  at  the  seat  of  implantation  consists  of  cellular  elements 
formed  by  the  tissues  of  the  vessel-wall.  As  soon,  however,  as 
bacilli  reach  the  extra-vascular  tissues,  they,  in  turn,  furnish 
their  part  of  the  material  for  the  further  growth  of  the  nodule. 
If  the  tubercle  bacillus  become  implanted  upon  a  mucous  sur- 
face,— as  the  bladder,  intestines,  nose,  larynx,  uterus,  etc., — if 
such  surface  is  susceptible  to  tubercular  infection,  the  epithelial 
cells  take  an  early  and  active  part  in  the  inflammatory  process. 
From  the  manner  of  entrance  into  and  diffusion  through  the 
tissues,  it  is  apparent  that  the  mesoblastic  tissues,  especially  the 
connective  tissue  and  endothelial  cells,  being  the  Jirst  to  become 
infected,  furnish  the  greatest  amount  of  the  new  material  in  most 
tubercular  lesions;  but  all  tissues,  when  infected,  take  part  in 
the  process. 


CHAPTER  VI. 

CASEATION. 

THE  gray  or  miliary  tubercle  is  transformed  into  the  yellow, 
crude,  or  cheesy  tubercle  by  a  process  which  is  called  caseation, 
or  tyrosis.  The  exact  nature  of  this  process  remains  unknown. 
The  cheesy  material  is  composed  of  the  products  of  cell-necrosis. 
Early  death  of  cells  is  the  most  characteristic  pathological  fea- 
ture of  tubercle,  wliicli  distinguishes  it  from  all  other  forms  of 
chronic  inflammation.  Two  causes  can  be  advanced  to  explain 
this  peculiar  and  almost  pathognomonic  form  of  degeneration, 
which  occurs,  almost  without  exception,  in  every  tubercle,  if  a 
sufficient  length  of  time  has  elapsed:  (1)  inadequate  blood- 
supply  ;  (2)  specification  of  the  bacillus  of  tuberculosis  or  its 
ptomaines.  Caseation  always  commences  in  the  centre  of  a 
nodule,  consequently  at  a  point  most  remote  from  the  vascular 
supply,  and  in  cells  which  have  been  exposed  longest  to  the 
deleterious  eifect  of  the  primary  microbic  cause.  Tubercle  is  a 
non-vascular  product.  From  causes  which  as  yet  are  not  fully 
understood,  vascularization  of  the  nodule  never  takes  place. 
The  angioblasts  in  the  infected  area  are  transformed  into  epi- 
thelioid  cells  that  have  lost  permanently  their  intrinsic  anatomi- 
cal structure  and  physiological  function.  Nodules  which  have 
primarily  an  intra-vascular  origin  are  rendered  avascular  by 
closure  of  the  vessel  from  intra-  and  peri-  vascular  cell-prolifera- 
tion. If  the  primary  starting-point  of  the  nodule  is  outside  of 
the  vessels  the  rapidly-accumulating  cells  exert  pressure  upon 
the  surrounding  vessels,  and  thus  diminish  the  blood-supply  to 
the  part  affected.  The  new  cells  require  an  adequate  quanti- 
tative and  qualitative  blood-supply  for  their  further  development, 
and  if  this  fail  to  take  place,  as  is  the  case  in  every  tubercular 
product,  they  necessarily  suffer  from  malnutrition,  and  undergo 
degenerative  changes  at  an  early  stage  of  their  existence.  A 
deficient  blood-supply,  in  the  absence  of  other  more  specific 
causes,  would  result  in  fatty  degeneration ;  but  caseation  is 
(46) 


CASEATION.  47 

something  different  from  ordinary  fatty  degeneration,  and  the 
bacillus  of  tuberculosis  or  its  ptomaines  must  be  regarded  as  its 
immediate  and  essential  cause.  Caseation  is  preceded  by  coagu- 
lation necrosis,  which  is  one  of  the  results  of  the  specific  action 
of  the  bacillus  on  the  tissues.  The  coagulation  necrosis  com- 
mences in  the  giant-cells  and  in  the  epithelioid  cells  in  the  centre 
of  the  nodule,  and  caseation  follows  as  soon  as  the  dead  cells 
have  lost  their  histological  identity  and  appear  under  the  micro- 
scope as  a  debris,  in  wliich  no  distinct  cell-forms  can  be  identi- 
fied. Caseation  is  attended  by  softening,  which  can  be  readily 
recognized  in  tubercular  masses,  the  size  of  a  hazel-nut  to  that 
of  a  walnut,  composed  of  numerous  confluent  nodules,  with  as 
many  caseating  foci.  In  such  masses  the  small,  cheesy  foci 
become  confluent  and  form  larger  caseous  centres.  Caseation 
proceeds  from  the  centre  of  each  nodule  toward  the  periphery, 
layer  after  layer  of  epithelioid  cells  being  destroyed  and  changed 
into  cheesy  material.  The  part  of  a  tubercle-nodule  which  has 
undergone  caseation  contains  few  or  no  bacilli,  and  yet  inocula- 
tion experiments  show  it  to  be  highly  infectious.  The  cheesy 
material  does  not  furnish  the  proper  nutrient  material  for  the 
growth  and  development  of  the  bacillus,  which  dies  from  star- 
vation, while  the  spores,  being  more  durable  and  possessing 
greater  power  of  resistance,  remain  in  an  active  condition  for  an 
indefinite  period  of  time  in  the  caseous  material,  and  it  is  due 
to  their  presence  that  infection  takes  place  from  old,  cheesy  foci, 
and  that  successful  inoculations  can  be  made  with  cheesy  ma- 
terial. While  the  disease  has  become  arrested  in  the  centre  of 
a  nodule,  with  the  appearance  of  caseation,  its  growth  in  a 
peripheral  direction  pursues  the  same  relentless  course.  The 
bacilli  multiply  in  fresh  tubercular  tissue,  and  are  carried  beyond 
the  peripheral  zone  into  the  surrounding  tissues,  where  new, 
independent  foci  of  infection  are  established,  which,  in  the 
course  of  time,  pass  through  the  same  series  of  pathological 
changes  as  the  primary  nodules.  It  is  a  well-known  clinical 
fact  that  acute  miliary  tuberculosis  is  not  a  primary  affection, 


48  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

as  ill  all  such  cases  a  careful  post-mortem  examination  will 
reveal  the  presence  of  a  cheesy  focus  in  a  lymphatic  gland,  the 
lungs,  testicles,  a  joint,  or  bone,  or  some  other  organ  from  which 
the  general  infection  occurred.  A  cheesy  mass  is,  therefore, 
always  a  source  of  danger,  as  it  may  become  the  distributing- 
point  of  the  essential  cause  of  tuberculosis,  and  produce  gen- 
eral miliary  tuberculosis  years  after  the  local  disease  has  been 
arrested.  The  cheesy  material  may  lie  latent  for  twenty  to  fifty 
years  as  long  as  it  remains  firm  and  encysted,  but  as  soon  as  it 
undergoes  softening  and  liquefaction  the  spores  which  it  con- 
tains can  be  taken  up  by  the  blood-vessels  and  become  then  the 
cause  of  general  infection. 


CHAPTER   VII. 

TUBERCULAR  ABSCESS. 

THE  pathogenic  effect  of  the  bacillus  of  tuberculosis  on  the 
tissues  is  to  produce  a  chronic  inflammation,  which  invariably 
results  in  the  production  of  granulation  tissue.  The  embryonal 
cells  furnish,  as  it  were,  a  wall  of  protection  for  the  time  being 
for  the  surrounding  healthy  tissue.  The  characteristic  patho- 
logical feature  of  every  tubercular  product  consists  in  the  tend- 
ency of  the  cells  of  which  it  is  composed  to  undergo  early  degen- 
erative changes,  which  are  caused  by  local  ischaemia  and  the 
specific  chemical  action  of  the  ptomaines  of  the  tubercle  bacilli, 
and  consist  in  coagulation  necrosis,  caseation,  and  liquefaction 
of  the  cheesy  material  into  an  emulsion,  which  has,  until  quite 
recently,  always  been  regarded  as  pus,  until  modern  researches 
have  shown  that  it  is  simply  the  product  of  retrograde  tissue 
metamorphosis,  and  not  true  pus,  I  believe  that  it  can  now  be 
considered  as  a  settled  fact  that  the  bacillus  of  tuberculosis  is 
not  a  true  pyogenic  microbe,  and  that  in  the  absence  of  other 
microbes  it  produces  a  specific  form  of  chronic  inflammation, 
which  invariably  terminates  in  the  formation  of  granulation 
tissue ;  and  that,  when  true  suppuration  does  take  place  in  the 
tubercular  product,  it  occurs  in  consequence  of  secondary  infec- 
tion with  pus-microbes.  The  earliest  commencement  of  such 
an  abscess  is  a  small  nodule,  which  slowly  increases  in  size  to 
that  of  a  walnut,  when  softening  takes  place  in  the  centre  by 
degeneration  and  liquefaction  of  the  inflammatory  product. 
The  solid  mass  at  first  is  composed  of  confluent  tubercles. 
Liquefaction  of  the  caseous  material  takes  place  by  imbibition 
of  fluids.  In  the  walls  of  the  primary  abscess  new  foci  liquefy, 
and  thus,  by  increase  of  the  liquid  contents  of  the  first  cavity, 
and  by  the  addition  of  new  spaces,  the  abscess-cavity  is  enlarged 
to  the  enormous  dimensions  so  frequently  met  with  at  the  bed- 
side in  the  treatment  of  tubercular  affections  of  bones  and  joints. 

At  the  last  meeting  of  the  French  Congress  of  Tubercu- 

(49) 


50  TUBERCULOSIS   OF   THE    BONES    AND   JOINTS. 

losis  (1891),  Hallopeau  stated  his  belief  that  cold  abscesses  are 
caused  by  chemical  products  of  the  tubercle  bacillus  independ- 
ently of  the  microbes  of  suppuration  proper. 

Arloing  diminished  the  virulence  of  the  tubercular  virus 
by  heating,  and  produced  with  it  limited  suppuration, — a  result 
which  agreed  with  the  statement  previously  made  by  Koch. 
Verneuil  and  Beretta  spoke  of  the  transformation  of  cold  or 
chronic  into  hot  or  acute  abscesses,  a  change  which  is  occasion- 
ally observed  in  tubercular  lesions,  and  which  they  attribute  to 
the  presence  and  action  of  pyogenic  microbes,  especially  the 
streptococcus.  In  their  experience  such  a  change  always 
resulted  in  a  cure,  whether  the  abscess  opened  spontaneously 
or  was  incised.  They  maintain  that  the  pus-microbes  destroy 
the  tubercle  bacillus.  The  so-called  tubercular,  congestive, 
wandering,  or  cold  abscess  contains  a  fluid  which,  macroscopi- 
cally,  resembles  pus,  but  which,  when  examined  under  the 
microscope,  shows  none  of  its  characteristic  histological 
elements. 

Chemical  Analysis. — Lannelongue  ("  Absces  froids  et 
tuberculose  osseuse."  Paris,  1881),  in  comparing  the  pus  con- 
tained in  cold  abscess  with  the  pus  bonum,  calls  attention  to  the 
fact  that  the  former  contains  a  much  lesser  quantity  of  solid 
constituents,  and  the  quantity  of  albumen  is  correspondingly 
less.  He  gives  the  following  result  of  a  chemical  analysis  of 
tubercular  pus : — 

Serum  (949.30).  Solid  Ingredients  (50.70). 

Mucin, 13.82      Pus-corpuscles, 5.16 

Serum-albumen 25.57      Cholesterin,    >  .  ft~ 


Metalbunien, 13.07  Lecithin, 

Cholesterin, 4.50  Inorganic  salts, 0.52 

Leucin  and  similar  substances,  .       7.25  Water 43  87 

Inorganic  salts, 6.44  Undetermined  substances,      .     .      0.13 

Water, 877.20 

If  such  a  chronic  cold  abscess  is  converted  into  an  acute 
hot  abscess,  it  is  almost  positive  proof  that  a  secondary  or 
mixed  infection  with  pus-microbes  has  occurred.  Tubercular 


TUBERCULAR  ftfefeSOE  ~  5  J. 


3  T  E  G  P  A  T  K  I  C 

~ 


pus  can  usually  be  distinguished  from  ordinary  pus,  without 
much  difficulty,  by  its  macroscopical  appearances.  Tubercular 
pus,  so-called,  is  an  emulsion  which  presents  a  whitish  or  almost 
chalky  appearance,  in  which  minute  fragments  of  dead  tissue 
and  shreds  of  fibrin  are  suspended,  while  ordinary  pus  is  a 
homogeneous  fluid,  of  the  consistence  of  thin  cream,  presenting 
a  yellowish  appearance,  with  a  tinge  of  green.  If  the  bacillus 
of  tuberculosis  meets  with  sufficient  resistance  on  the  part  of 
the  surrounding  tissues,  it  finally  exhausts  the  nutrient  material 
in  the  granulations  and  dies,  or  remains  in  a  latent  condition  ; 
the  sterile  granulation  material  is  converted  into  cicatricial  tissue 
and  the  local  lesion  is  cured.  The  cases  in  which  the  tubercular 
product  is  removed  by  cicatrization  terminate  most  frequently  in 
spontaneous  cure.  If,  on  the  other  hand,  bacilli  in  sufficient 
number  are  present  to  destroy  the  granulation  cells,  coagulation 
necrosis,  caseation,  and  liquefaction  of  the  infected  tissue  take 
place  ;  a  spontaneous  cure  is  still  possible  if  a  part  of  the  fluid 
portion  is  absorbed  and  the  solid  debris  becomes  encapsulated. 
The  same  favorable  termination  is  expedited,  under  similar  cir- 
cumstances, if  the  primary  lesion  has  healed  and  the  inflamma- 
tory product  is  removed  by  operative  interference,  under  strictest 
antiseptic  precautions  ;  or  if,  at  the  same  time,  the  primary 
focus  can  be  completely  removed  by  extending  the  operation  to 
the  primary  lesion.  Secondary  infection  of  a  tubercular  product 
with  pus-microbes,  without  a  direct  infection  atrium,  is  possible, 
although  practically  a  very  infrequent  occurrence,  and,  if  the 
primary  lesion  is  located  in  an  unimportant  organ,  and  in  such 
a  place  where  the  inflammatory  product  can  be  reached  at  an 
early  stage,  or  can  be  eliminated  spontaneously,  a  cure  is  often 
effected,  as  the  suppurative  inflammation  frequently  proves 
successful  in  destroying  all  of  the  tissues  inhabited  by  the 
bacillus,  and  the  whole  nidus,  with  the  microbes  it  contains,  is 
eradicated  permanently  from  the  body.  Such  a  course  is  not 
seldom  observed  in  cases  of  tuberculosis  of  the  lymphatic 
glands  of  the  neck.  If,  however,  the  tubercular  process  affect 


52  TUBERCULOSIS   OP   THE    BONES   AND   JOINTS. 

important  organs,  or  parts  deeply  located,  with  extensive 
infection  of  tissue,  and  secondary  infection  with  pus-microbes 
takes  place,  then  the  patient  incurs  the  danger  of  septic  infec- 
tion and  local  and  general  dissemination  of  the  tubercular 
process,  from  the  breaking  down  of  the  protective  wall  of 
granulation  tissue. 

Garre  has  shown  that  pus-microbes  grow  luxuriantly  in 
the  soil  furnished  by  a  tubercular  abscess,  while  they  do  not 
grow  in  ordinary  pus.  Watson  Cheyne  states  that  liquefaction 
of  the  tubercular  product  is  determined  by  the  constitution  of 
the  patient,  as  it  occurs  most  frequently  in  persons  in  whom  the 
disease  is  hereditary.  That  the  bacilli  do  not  multiply  in  a 
tubercular  abscess  has  been  definitely  settled  by  Schlegtendal. 
He  examined  520  specimens  of  fluid  taken  from  tubercular 
abscesses,  and  found  bacilli  present  in  only  75  per  cent.  Garre 
("  Zur  ^Etiologie  der  kaltenabscesse,  Driiseneiterung,  Weich- 
theil  u.  Knochen  Abscesse  u.  der  tuberculosen  Gelenkeiter- 
ungen."  Deutsche  Med.  Wbchenschrtft,  B.  xxi,  No.  34,  1886.) 
has  also  made  an  extended  series  of  observations  to  ascertain 
the  presence  of  the  bacillus  in  cold  abscesses.  He  examined 
the  contents  of  tubercular  abscesses  in  thirty  cases,  and  only 
seldom  found  bacilli.  Cultivation  experiments  proved  usually 
also  negative,  but  inoculations  yielded  always  positive  results. 
He  believes  that  tubercular  pus  contains  many  active  spores 
after  the  bacilli  have  disappeared.  According  to  this  author, 
many  tubercular  ulcerations  and  abscesses  are  the  result  of  a 
mixed  infection,  as  has  been  claimed  by  HofFa  for  some  cases  of 
empyema  complicating  pulmonary  or  pleura!  tuberculosis.  In 
cold  abscesses,  and  in  the  liquefied,  cheesy  material  of  tubercu- 
lar cavities  in  bones  and  joints,  no  pus-microbes  could  be  found, 
not  even  in  cases  that  pursued  a  rapid  course.  Cultivations 
made  with  such  material  remained  sterile,  while  inoculations 
produced  typical  tuberculosis  in  animals.  Specimens  of  such 
fluid,  examined  under  the  microscope,  showed  none  of  the 
morphological  elements  of  pus,  but  were  seen  to  consist  of  an 


TUBERCULAR   ABSCESS.  53 

emulsion  of  fat-globules  and  detritus  of  broken-down  tissue, 
suspended  in  serum.  Garre  believes  it  is  possible  that,  in 
many  cases  of  suppuration  following  in  the  course  of  a  tuber- 
cular process,  pus  is  the  result  of  a  mixed  infection,  and  that 
the  pus-microbes  disappear  before  the  examination  is  made. 

Tavel  ("  Beitrag  zur  ^Etiologie  der  Eiterung  bei  Tubercu- 
lose.  Separat  Abdruck  aus  den  Beitragen  zur  Chimrgie.  Fest- 
schrift, herausgegehen  zu  Ehren  des  Professor  Kocher  in  Bern., 
1891 ")  has  made,  recently,  a  valuable  contribution  to  the 
etiology  of  suppuration  in  tubercular  lesions.  In  his  classifica- 
tion of  suppuration  Verneuil  has  divided  pus  into  "  mono  et 
poly-  microbique"  and  brings  tubercular  pus  under  the  latter 
head,  as  he  believes  it  is  the  product  arising  from  the  action  of 
both  tubercle  bacilli  and  pus-microbes. 

Garre,  Krause,  and  Steinhaus  are  of  the  opinion  that  tuber- 
cular pus  is  in  reality  no  pus,  but  simply  the  product  of  cellular 
disintegration  brought  about  by  the  bacillus  of  tuberculosis. 
G.  Roth  and  de  Ruyter  regard  tubercular  pus  as  the  product  of 
a  mixed  infection  following  invasion  of  a  tubercular  product 
with  pus-microbes.  In  the  Berlin  Hygienic  Institute  experi- 
ments made  with  Koch's  lymph  showed  that  large  quantities 
injected  subcutaneously  in  animals  produced  a  circumscribed 
suppuration,  which  appears  to  demonstrate  that  the  chemical 
products  of  tubercle  bacilli  possess  mild,  facultative,  pyogenic 
properties.  Inoculation  experiments  almost  invariably  result  in 
the  formation  of  an  abscess  at  the  point  of  inoculation,  and  the 
pus  contained  no  other  microbes  besides  tubercle  bacilli.  It  has 
recently,  also,  been  shown  that  syphilitic  gummata  and  actino- 
mycotic  foci  may  become  the  seat  of  suppuration  without  an 
additional  infection,  and  at  the  same  time  the  pyogenic  proper- 
ties of  the  bacillus  of  glanders  has  been  demonstrated.  The 
typhoid  bacillus,  the  gonococcus,  the  pneumococcus,  the  mi- 
crobe of  scarlatina,  and  the  anthrax  bacillus  are  known  to 
cause,  at  least  occasionally,  suppuration.  Tavel  studied  the 
contents  of  tubercular  abscesses  by  means  of  stained  preparations 


54  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

under  the  microscope,  by  cultivation  and  inoculation  experi- 
_ments,  taking-  special  precautions  to  prevent  contamination  of 
the  material  after  its  removal  from  subcutaneous  tubercular 
lesions.  In  the  selection  of  cases  special  pains  were  taken  to 
study  those  which  pursued  a  subacute  course  in  which  the  sus- 
picion of  the  existence  of  a  mixed  infection  could  be  entertained. 
In  all,  forty  cases  were  subjected  to  a  critical  examination  as  to 
the  presence  of  mixed  infection,  and  in  all  of  these  a  positive  or 
probable  diagnosis  of  tuberculosis  was  made  before  the  opera- 
tion. In  the  first  thirty  cases  of  tubercular  abscess  the  exclusive 
presence  of  the  tubercle  bacillus  was  demonstrated  by  inocula- 
tion experiments  and  the  clinical  course  of  the  lesions  from 
which  the  material  was  obtained.  In  the  first  five  cases  the 
results  of  the  inoculation  experiments  and  the  clinical  course 
proved  the  tubercular  nature  of  the  lesions.  Besides  tubercle 
bacilli,  streptococci  or  staphylococci  were  found  in  the  cases  of 
mixed  infection.  The  haematogenetic  origin  of  this  mixed  in- 
fection could  be  excluded,  as  in  all  cases  a  connection  could  be 
found  between  the  focus  and  the  external  or  internal  surface  of 
the  body.  In  the  last  five  cases,  in  which  he  demonstrated 
ha3inatogenetic  infection  with  the  streptococci  and  staphylococci, 
and  in  which  the  clinical  course  before  the  operation  spoke  for 
tuberculosis,  the  subsequent  course,  as  well  as  inoculation  ex- 
periments, showed  that  they  were  memo  infections,  and  that 
here  the  tubercle  bacillus  was  out  of  question.  From  these 
experiments  and  clinical  observations,  he  came  to  the  conclusion 
that  the  mixed  infections  with  a  haematogenetic  origin  are 
exceedingly  rare.  In  most  of  the  cases  of  mixed  infection  some 
connection  with  the  surface  of  the  body  can  usually  be  demon- 
strated. The  author  is  of  the  same  opinion  as  Garre,  that 
tubercular  abscesses  are  caused  exclusively  by  the  tubercle 
bacillus ;  but,  unlike  Garre,  he  believes  that  the  process  is  the 
same,  or  at  least  very  similar,  during  the  early  stages  of  a  tuber- 
cular affection,  and  in  acute  cases,  as  in  acute  suppurative 
inflammation,  attributing  to  the  chemical  products  of  tubercle 


TUBERCULAR   ABSCESS.  55 

bacilli  mild  pyogenic  properties.  According  to  the  author,  the 
leucocytes  and  embryonal  cells  of  the  inflammatory  product  of 
the  fixed  tissue-cells  are  first  transformed  into  pus-corpuscles, 
and  that  these  undergo  later  fatty  degeneration,  and,  after  com- 
plete disintegration,  furnish  the  granular  detritus  which  has 
been  regarded  as  the  characteristic  part  of  tubercular  pus.  As 
the  greatest  difference  between  pus-corpuscles  in  acute  and 
tubercular  abscesses,  he  regards  a  more  speedy  granular  degen- 
eration and  disintegration  of  the  latter.  A  tubercular  abscess  is 
always  lined  by  a  tubercular  membrane,  which  contains  the 
typical  structure  of  the  tubercular  lesion  and  the  primary  and 
essential  cause  of  the  inflammation, — the  bacillus  of  tuberculosis. 
The  tension  in  such  abscesses  is  much  less  than  in  abscesses 
caused  by  acute  phlegmonous  suppuration,  and  on  this  account 
fluctuation  is  a  well-marked  symptom  in  most  cases. 

Lannelongue  ("  De  la  tension  dans  les  absces  Tubercu- 
leaux."  Bull,  de  la  Soc.  de  Chir.,  December  23,  1886)  exam- 
ined, by  means  of  a  modified  Ludvvig  hsemo-dynamometer,  the 
degree  of  tension  in  tubercular  abscess  of  the  extremities,  and 
found  it,  as  a  rule,  equal  to  the  blood-pressure  in  veins  between 
12  and  22  millimetres.  Only  in  abscesses  of  the  wall  of  the 
thorax  was  the  tension  higher  in  consequence  of  respiration- 
pressure,  which  increased  it  to  30  to  50  millimetres.  During 
continued  extension  with  3  kilogrammes'  weight,  and  after  in- 
jection of  iodoform  ether,  the  pressure  was  increased  in  for- 
mer instances  to  60  millimetres,  and  in  the  latter  case  50 
to  80  millimetres,  mercury-pressure.  The  thickness  of  this 
membrane  depends  on  the  length  of  time  the  abscess  has 
existed  and  the  duration  of  the  infection.  This  membrane 
is  formed  by  the  extension  of  the  tubercular  process  from 
the  primary  starting-point  to  the  surrounding  tissues.  The 
color  of  the  membrane  is  yellowish  gray  or  grayish  violet.  It 
is,  on  an  average,  a  few  millimetres  in  thickness  and  loosely 
attached  to  the  subjacent  tissues.  This  membrane  is  the  most 
characteristic  anatomical  feature  of  every  tubercular  abscess,  as 


56  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

it  is  never  found  in  any  other  abscess,  and  bears  a  very  strong 
resemblance  to  the  wall  of  an  echinococcus-cyst.  It  consists  of 
fragile  tissue,  which  is  composed  essentially  of  heaps  of  miliary 
tubercles.  Between  the  tubercles,  and  upon  the  surface  of  the 
membrane,  masses  of  coagulated  lymph  can  be  found.  If  the 
membrane  is  rich  in  tubercles  it  presents  somewhat  the  appear- 
ance of  frogs'  spawn. 

The  surface  is  often  dotted  with  yellowish  spots,  each  one 


FIG.  14.— ABSCESS-MEMBKANE  FROM  A  TUBERCULAR  ABSCESS. 
Surface  view,  slightly  enlarged.     ( Volkmann.) 

of  which  is  a  caseation-centre.  At  times  such  abscess-cavities 
are  spanned  by  strings  of  connective  tissue,  which  are  also  cov- 
ered with  tubercles,  and  when  torn  or  cut,  during  the  operative 
treatment  of  the  abscess,  often  give  rise  to  troublesome  haemor- 
rhage. In  scraping  out  such  abscesses  with  a  sharp  spoon  the 
greatest  caution  must  be  exercised  to  remove  every  particle  of 
the  membrane,  as  incomplete  removal,  almost  without  excep- 
tion, is  followed  by  relapse.  Often,  after  thorough  scraping, 
examination  will  reveal  islets  of  tubercular  tissue,  which  must 


TUBERCULAR   ABSCESS.  57 

be  removed  separately.  After  spontaneous  evacuation  of  a 
tubercular  abscess,  or  after  incomplete  removal  of  the  infected 
tissue,  a  tubercular  fistula  forms.  Such  fistulse  are  always  lined 
with  soft  granulations,  which  appear  in  a  wonderfully  short 
time.  The  softness,  pallor,  and  oedematous  appearance  of  these 
granulations,  lining  the  tract  and  opening  of  such  fistulas,  dis- 
tinguish these  granulations  from  syphilitic  and  osteomyelitic 
inflammatory  products  in  similar  tissues  and  localities.  In 
exceptional  cases  the  tubercular  infiltration  from  the  abscess- 
wall  extends  to  the  muscles,  which  then  become  the  seat  of  a 
typical  tubercular  myositis.  Such  abscesses  often  travel  great 
distances ;  for  instance,  from  the  bodies  of  the  verteb.rse  down 
to  and  below  Poupart's  ligament.  The  entire  track  over  which 
they  have  passed  is  lined  by  the  tubercular  membrane,  the 
abscess  and  the  primary  lesion  being  connected  with  an  uninter- 
rupted path  of  tubercular  tissue.  The  infection  follows  the 
migration  of  the  abscess,  in  whatever  direction  that  may  take 
place.  If  an  additional  infection  from  without  take  place,  fol- 
lowing either  a  spontaneous  discharge  or  after  incision,  the 
superficial  granulations  are  destroyed  by  the  suppurative  process 
which  is  initiated,  exposing  the  patient  to  the  additional  risks  of 
septic  infection  and  a  more  rapid  local  and  general  dissemination 
of  the  tubercular  process. 

Symptoms  and  Diagnosis.  — -  The  tubercular  abscess  is 
called  a  cold  abscess  because  it  lacks  tUe  characteristic  clinical 
phenomena  which  attend  the  development  of  an  acute  or  hot 
abscess.  There  is  but  little,  if  any,  rise  of  the  local  tempera- 
ture, and,  unless  the  abscess  has  reached  the  skin,  the  surface 
looks  rather  preternaturally  pale  than  red,  and  the  abscess  itself 
is  always  painless,  and  not  tender  on  pressure.  The  pain,  if 
present,  is  referred  to  the  primary  seat  of  the  tubercular  inflam- 
mation. Fluctuation  is  usually  well  marked,  as  the  tissues 
around  the  abscess  are  not  much  infiltrated.  The  most  impor- 
tant clinical  feature  of  a  cold  abscess  is  its  tendency  to  migrate 
from  the  place  where  it  originated  to  distant  localities  by  gravi- 


58  TUBERCULOSIS   OF   THE   BONES  AND   JOINTS. 

tation ;  hence  the  name  given  to  it  by  German  writers, — Sen- 
kungsabscess.  Thus,  in  tubercular  spondylitis,  the  abscess  may 
appear  in  the  lumbar  region,  and  is  then  called  lumbar  abscess  ; 
it  may  follow  the  iliac  muscle  and  appear  in  one  of  the  iliac 
regions,  and  is  then,  from  its  location,  termed  iliac  abscess  ;  or, 
finally,  it  may  follow  the  psoas  muscle  and  appear  above  or 
below  Poupart's  ligament,  when  it  constitutes  a  psoas  abscess. 
In  tuberculosis  of  the  hip-joint  the  abscess  appears  posteriorly 
underneath  the  gluteal  muscles,  if  perforation  of  the  capsule 
take  place  in  this  direction  ;  or  it  appears  anteriorly,  usually  a 
considerable  distance  below  the  hip-joint,  if  perforation  of  the 
capsule  has  taken  place  in  an  opposite  direction.  As  the  con- 
tents of  the  abscess  carry  the  original  cause  of  the  disease, 
infection  of  the  tissues  takes  place  along  the  whole  course 
traveled  by  the  abscess,  which  is  always  lined  with  infected 
granulation  tissue.  Although  the  primary  cause  of  a  tubercu- 
lar abscess  is  most  frequently  tuberculosis  of  a  bone  or  joint,  it 
can  also  develop  in  the  course  of  any  localized  form  of  tubercu- 
losis, and  it  is  quite  frequently  met  with  in  the  course  of  tuber- 
culosis of  the  lymphatic  glands.  One  of  the  largest  tubercular 
abscesses  in  the  iliac  fossa  that  ever  came  under  my  observation 
formed  in  the  course  of  two  weeks  after  extirpation  of  a  tuber- 
cular testicle.  The  affection  of  the  spermatic  cord  extended 
beyond  the  internal  inguinal  ring,  and  the  part  not  removed 
undoubtedly  served  as  -the  starting-point  of  the  abscess.  The 
diagnosis  must  be  made  with  special  reference  to  the  nature  and 
location  of  the  primary  lesion.  In  tuberculosis  of  the  spine,  the 
fixed  pain  in  the  region  of  the  affected  vertebrae,  radiating  from 
here  in  the  direction  of  the  nerves,  taking  their  exit  from  the 
affected  part  on  each  side,  is  an  important  symptom,  and  this 
symptom  is  always  aggravated  by  flexion  and  alleviated  by 
extension  of  the  spine.  In  coxitis  the  pain  in  the  beginning 
of  the  disease,  especially  in  the  osseous  form,  is  usually  referred 
to  the  inner  aspect  of  the  knee-joint,  and  is  always  increased  by 
motion  of  the  hip-joint,  and  by  making  pressure  over  the  tro- 


TUBERCULAR   ABSCESS.  59 

chanter  in  the  direction  of  the  axis  of  the  neck  of  the  femur. 
In  cold  abscess  caused  by  glandular  tuberculosis,  the  clinical 
history  will  point  to  a  chronic  inflammation  of  the  glands  which 
preceded  the  formation  of  the  abscess.  Fluctuation  is  usually 
a  well-marked  symptom.  As  soon  as  the  abscess  reaches  the 
skin,  that  structure  becomes  inflamed,  red,  and  more  and  more 
attenuated  by  pressure  and  inflammation,  until  spontaneous 
perforation  takes  place  at  a  point  subjected  to  greatest  pressure. 
If  a  tubercular  abscess  become  the  seat  of  a  secondary  infec- 
tion witli  pus-microbes,  the  subsequent  symptoms,  local  and 
general,  are  suddenly  changed,  and  are  then  those  of  an  acute 
suppurative  inflammation.  The  temperature  —  which  was 
normal,  or  nearly  so — increases,  and  presents  the  daily  curves 
characteristic  of  acute  suppuration  and  the  general  symptoms 
arising  from  it  are  those  of  septic  infection,  while  the  abscess, 
which  has  been  heretofore  painless,  becomes  painful,  hot,  and 
tender  on  pressure ;  in  fact,  the  clinical  picture  indicates  that  a 
chronic  inflammation  has  been  supplanted  by  an  acute  one.  If 
any  doubt  remain  as  to  the  character  of  the  swelling  and  the 
nature  of  its  contents,  this  can  be  dispelled  at  once  by  resorting 
to  an  exploratory  puncture.  In  cold  abscess  the  fluid  removed 
presents  the  appearance  of  serum  in  which  minute  particles  of 
broken-down  tissues  are  suspended,  while  in  an  abscess  caused 
by  a  mixed  infection  it  presents  the  macroscopical  and  micro- 
scopical appearances  of  true  pus. 

Prognosis. — The  danger  attending  tubercular  abscess  must 
be  estimated  by  the  extent  and  location  of  the  primary  disease, 
the  presence  or  absence  of  secondary  infection,  and  the  general 
condition  of  the  patient.  An  open  tubercular  abscess,  which 
has  become  infected  with  pyogenic  microbes,  and  which  com- 
municates with  an  important  bone  or  joint,  is  always  a  serious 
source  of  danger  to  life.  Such  a  condition  is  also  unfavorable,  in 
reference  to  successful  surgical  treatment,  in  obtaining  a  satisfac- 
tory functional  result.  The  treatment  by  iodoformization  holds  out 
little  encouragement  in  securing  a  permanent  result,  and  operative 


60  TUBERCULOSIS   OF   THE    BONES   AND    JOINTS. 

treatment  usually  becomes  an  urgent  necessity.  If  'suppuration 
has  given  rise  to  organic  disease  of  any  of  the  important  internal 
organs  the  prognosis  is  always  grave,  as  the  removal  of  the 
primary  cause  by  operative  treatment  will  not  prove  successful 
in  averting  a  fatal  termination  from  the  complicating  lesions. 
Tuberculosis  in  other  organs  renders  the  case  almost  necessarily 
fatal.  If  the  general  health  remain  unimpaired,  even  an  exten- 
sive local  tubercular  disease  may  be  amenable  to  a  spontaneous 
cure  or  successful  surgical  treatment.  On  the  other  hand,  a 
tubercular  abscess  developing  in  the  course  of  an  insignificant 
and  unimportant  local  lesion  occurring  in  an  anaemic  person, 
the  subject  of  incipient  multiple  foci  in  different  organs,  must 
be  regarded  as  a  most  formidable  condition,  with  little  or  no 
prospects  of  a  favorable  termination.  From  quite  an  extensive 
clinical  experience  with  cases  of  tuberculosis  of  bones  and  joints, 
I  have  learned  to  regard  pronounced  anosmia  as  an  unfavorable 
symptom  in  the  different  forms  of  surgical  tuberculosis^  as  it  is 
often  an  expression  that  general  infection  has  occurred  or  that 
important  internal  organs  are  the  seat  of  serious  organic  changes. 
Another  important  matter  to  be  taken  into  consideration  in  mak- 
ing a  prognosis,  in  cases  in  which  general  infection  can  be  ex- 
cluded, is  the  possibility  of  eradicating  the  primary  lesion  by 
operative  interference.  If  the  disease  is  so  located  that  this  can 
be  done,  the  chances  of  successful  treatment  of  the  local  disease 
are  much  better  than  if  the  opposite  is  the  case ;  at  the  same 
time,  the  complete  removal  of  the  infected  tissues  is  the  best 
possible  guarantee  against  general  infection.  Other  things  being 
equal,  the  prognosis  is  better  in  patients  without  a  hereditary  his- 
tory of  tuberculosis,  and  in  young  subjects  than  those  advanced 
in  years. 

Treatment. — Patients  suffering  from  suppurating  tubercular 
cavities  require  nutritious  food,  ale,  porter,  or  some  of  the  sub- 
stantial wines,  as  Tokayer,  Aussbruch,  port,  or  sherry  ;  out-door 
air  will  often  prove  the  best  tonic.  Change  of  residence  to  the 
country,  the  sea-shore,  or  some  mountain-resort  has  often  been 


TUBERCULAR   ABSCESS.  61 

known  to  effect  a  cure  when  recovery  was  despaired  of  as  long 
as  patients  lived  in  less  favorable  localities.  In  the  way  of 
medication  the  treatment  must  be  purely  symptomatic.  Appe- 
tite is  restored  by  the  use  of  bitter  tonics ;  anaemia  is  treated  by 
the  administration  of  some  mild  preparation  of  iron,  as  the 
syrup  of  iodide  of  iron,  tincture  of  chloride  of  iron,  albuminate 
of  iron,  or  citrate  or  tartrate  of  iron.  If  codliver-oil  is  given, 
it  should  be  administered  pure,  and  not  in  emulsion,  and  never 
upon  an  empty  stomach.  Holler's  pale  Norwegian  oil  is  the 
best  and  most  palatable.  It  can  be  given  floating  upon  any 
agreeable  menstruum,  such  as  black  coffee,  brandy,  whisky,  or 
wine.  The  best  time  to  administer  the  drug,  without  disturb- 
ing the  digestion,  is  an  hour  or  an  hour  and  a  half  after  each 
meal,  in  doses  of  from  a  teaspoonful  to  a  tablespoonful,  accoixU 
ing  to  the  condition  of  the  digestion  and  the  age  of  the  patient. 
Tapping  of  Abscess,  Followed  by  Antiseptic  Irrigation  and 
Subcutaneous  lodoformization. — This  method  of  treatment  will 
be  more  fully  described  in  another  part  of  the  book,  to  which 
the  reader  is  referred.  This  treatment  has  been  followed  by 
most  signal  success  in  the  treatment  of  tubercular  abscesses, 
and  should  invariably  receive  a  faithful  trial  before  operative 
measures  are  resorted  to.  The  procedure  should  be  repeated 
every  two  weeks  until  the  abscess-cavity  has  become  obliterated. 
Washing  out  of  the  cavity  with  a  4-per-cent.  solution  of  boracic 
acid  prior  to  the  injection  of  the  iodoform  emulsion  is  of  great 
importance  and  value,  as  it  secures  more  thorough  removal  of 
the  dead,  broken-down  tubercular  tissue,  thus  bringing  the 
cavity  in  a  more  favorable  condition  for  the  antibacillary  action 
of  the  iodoform.  If  the  treatment  prove  successful,  re-accumu- 
lation takes  place  more  slowly  and  the  character  of  the  tubercu- 
lar pus  changes.  As  soon  as  an  active  reparative  process  has 
been  initiated  the  granulations  lining  the  cavity  no  longer 
undergo  caseation,  and  the  fluid  removed  at  this  time  is  scanty 
and  resembles  mucus  more  than  pus.  In  a  number  of  cases 
that  have  come  under  my  observation  I  have  found,  after  the 


62  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

second  or  third  injection,  a  moderate  swelling,  which  presented 
well-marked  fluctuation,  but  which,  when  punctured,  yielded 
no  fluid.  The  swelling  and  fluctuation  were  evidently  due  to 
the  presence  of  a  mass  of  granulation  tissue,  which  was  under- 
going transformation  into  permanent  tissue.  I  have  always,  in 
such  cases,  made  the  iodoform  injection,  and  in  a  few  weeks  the 
abscess  was  found  healed,  and  the  swelling  gradually  disap- 
peared. In  open,  suppurating,  tubercular  abscesses  this  treat- 
ment has  not  proved  as  successful  as  in  cases  of  uncomplicated, 
subcutaneous,  tubercular  lesions.  If  iodoformization  is  to  be 
employed  in  such  cases  it  should  be  preceded  by  measures 
directed  toward  the  suppuration,  and  thus  remove  the  cause 
and  inflammatory  products  of  the  secondary  infection.  Incision, 
scraping  of  inner  surface  of  abscess-wall,  and  thorough  applica- 
tion of  peroxide  of  hydrogen  will  answer  these  indications  most 
effectually.  After  the  abscess  has  been  rendered  aseptic  by 
such  treatment,  iodoformization  is  to  be  made  in  the  same  man- 
ner as  in  closed  tubercular  cavities.  The  most  rigid  antiseptic 
precautions  must  be  observed  in  order  to  prevent  a  new  infection 
with  pus-microbes. 

Incision  and  Removal  of  Infected  Tissue  by  Scraping. — 
In  all  cases  where,  from  the  anatomical  location  of  the  primary 
lesion,  it  is  possible  to  remove  the  tubercular  product  by  opera- 
tive interference,  and  the  patient  is  free  from  other  tubercular 
affections  and  other  fatal  complications,  a  radical  operation  is 
always  indicated  after  simpler  measures  have  failed  in  curing 
the  primary  affection.  In  such  cases  the  abscess-cavity  is  laid 
freely  open  in  a  direction  which  will  secure  most  ready  access 
to  its  interior  with  least  injury  to  surrounding  parts.  When- 
ever it  is  found  possible,  from  the  anatomical  relations  of  the 
parts,  the  incision  should  be  made  large  enough  to  expose  for 
direct  treatment  the  whole  of  the  interior  surface  of  the  abscess. 
After  the  abscess  has  been  incised,  its  contents  are  washed  away 
by  irrigating  with  an  aqueous  solution  of  iodine,  after  which  the 
granulations  lining  the  cavity  are  scraped  out  with  a  large, 


TUBERCULAR   ABSCESS.  63 

sharp  spoon,  and  the  primary  lesion  is  removed  in  a  similar 
manner.  In  dealing  with  such  cavities,  it  is  important  not  to 
forget  that  the  tubercle  bacilli  are  contained  in  the  granulations, 
because  if  these  are  not  completely  removed  the  principal  object 
of  the  operation — removal  of  the  primary  cause — has  not  been 
accomplished,  and  a  return  of  the  disease  is  to  be  expected.  In 
many  instances  prolongation  of  the  tubercular  membrane  be- 
tween the  interspaces  of  muscles  and  tendons  renders  it  neces- 
sary to  look  carefully  for  such  side-tracks  and  clear  them  of 
tubercular  material  with  the  sharp  spoon.  If  the  abscess  com- 
municate with  a  primary  focus  in  a  bone,  it  is  advisable  to 
resort  to  ignipuncture  of  the  bone  after  the  cavity  has  been 
cleared  of  the  granulations  with  the  sharp  spoon.  The  wound 
is  to  be  closed  in  the  usual  manner  after  iodoformization  of  the 
whole  surface,  leaving  only  a  small  opening  at  the  most  depend- 
ent point  for  drainage.  The  scraped  surfaces  are  now  in  the 
same  condition  for  primary  union  as  a  recent  aseptic  wound, 
and,  if  kept  in  accurate  apposition  by  the  antiseptic  dressing, 
which  answers  at  the  same  time  the  purpose  of  an  elastic  com- 
press, primary  union  throughout  is  frequently  obtained.  Ab- 
scesses which  have  opened  spontaneously,  or  during  the  treat- 
ment of  which  infection  has  occurred,  must  be  treated  on  the 
same  principles  as  acute  abscesses.  As  far  as  can  be  done,  the 
suppurating  granulations  should  be  removed  with  the  sharp 
spoon,  and  after  disinfection  and  iodoformization  efficient  tubu- 
lar drainage  established,  and,  if  the  ultimate  object  is  not 
attained  by  the  first  operation,  frequent  antiseptic  irrigations  are 
to  be  subsequently  made  until  the  cavity  has  been  rendered 
aseptic.  Landerer  has  recently  called  attention  to  the  value  of 
balsam  of  Peru  in  the  treatment  of  tubercular  abscesses.  He 
maintains  that  this  drug  acts  beneficially  by  stimulating  the 
tissues  to  renewed  activity;  thus  neutralizing  indirectly,  at  least 
to  a  certain  degree,  the  pathogenic  effect  of  the  bacilli,  while  at 
the  same  time  it  hastens  the  process  of  repair  by  its  stimulating 
action  on  the  tissues.  In  the  treatment  of  open,  suppurating, 


64  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

tubercular  surfaces  this  drug  should  be  tried  as  a  local  applica- 
tion. As  a  fluid  for  irrigation,  under  the  same  circumstances, 
nothing  can  surpass  the  efficacy  of  a  strong,  aqueous  solution 
of  tincture  of  iodine.  Rest  is  an  important  element  in  the  treat- 
ment of  tubercular  abscesses,  irrespective  of  their  location.  Pro- 
longed confinement  in  bed  and  room  should  be  avoided,  and 
rest  secured  by  appropriate  mechanical  support  while  the  patient 
enjoys  the  benefit  of  out-door  air  and  exercise. 


CHAPTER  VIII. 


TOPOGRAPHY  OF  BONE  AND  JOINT  TUBERCULOSIS. 

IT  is  a  well-known  clinical  and  experimental  fact  that  cer- 
tain bones  and  joints  are  predisposed  to  tubercular  infection. 

The  new  vessels  in  the  vicinity  of  the  centres  of  growth  in 
the  bones  of  young  persons,  on  account  of  their  imperfect  struc- 
ture and  irregular  contour,  furnish  the  most  favorable  conditions 
for  the  mechanical  arrest  of  floating  granular  matter  and 
the  localization  of  pathogenic  microbes.  This  predisposing 
anatomical  element  goes  far  to  explain  the  frequency  with 
which  we  meet  with  tubercular  foci  in  the  epiphysial  ex- 
tremities of  the  long  bones.  The  following  table,  prepared  by 
Schmalfuss  ("  Beitrage  zur  Statistik  der  chirurgischen  Tubercu- 
lose."  Archivf.  klin.  Chirurgie,  B.  xxxv,  S.  167)  gives  a  good 
idea  of  the  relative  frequency  with  which  different  bones  are 
affected  with  tubercular  lesions : — 


Billroth. 

Jaffe". 

Per 

cent. 

Schmalfuss. 

Per 

cent. 

Vertebra     .    .    . 

Vertebra          .    .   . 

26 

Knee 

23 

Knee                  .    . 

Foot          

21 

Foot 

19 

Cranium  and  face  •    .    . 

Hip    

13 

1  Hip    .    . 

16 

Hip  ...               ... 

Knee  

10 

Elbow 

9 

Sternum  and  ribs    .    . 

Hand  

9 

Hand 

8 

Foot     

Elbow  

4 

Vertebra 

75 

Elbow.           

Pelvis           

3 

Tibia  .    . 

4 

Cranium  ....... 

3 

Cranium 

4 

Tibia,  fibula,  and  femur 
Shoulder  

Sternum,  clavicle,  ribs  . 
Shoulder  

3 
2 

Pelvis    . 
Sternum,  etc. 
Femur  . 

3.6 
3.6 
1.9 

Femur  

1 

Shoulder 

1  5 

Humerus    

Tibia  

1 

Ulna  .    . 

1.4 

Ulna    

Fibula  ...           ... 

1 

Humerus 

1 

Radius    

Humerus         .... 

1 

Radius 

07 

Scapula       

06 

Fibula  . 

0.5 

Ulna  

06 

Patella  . 

0.1 

It  is  safe  to  state  that  before  puberty  the  primary  lesion  in 
tubercular  affections  of  joints  is  most  frequently  located  in  one 
or  both  of  the  epiphyses  of  the  bones  which  enter  into  the 

(65) 


66  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

formation  of  the  joint,  while  in  the  adult  primary  tuberculosis 
of  the  synovial  membrane  is  of  more  frequent  occurrence.  As 
age  advances  and  the  process  of  ossification  is  completed,  the 
predisposing  localizing  causes  in  bone  apparently  disappear, 
while  the  synovial  membrane  becomes  more  susceptible  to 
primary,  localization.  Of  204  specimens  of  tubercular  joints, 
obtained  from  patients  of  all  ages,  examined  by  Mueller,  158 
were  primary  osteal  and  46  primary  synovial  tuberculosis. 
The  predominance  of  the  osseous  form  in  these  figures  is 
owing  to  the  large  contingent  furnished  by  patients  under  the 
age  of  puberty. 

Jaffa's  ("  Ueber  Knochentuberculose."  Deutsche  Zeits- 
chrift  f.  Chirurgie,  B.  xviii,  S.  432)  statistic  is  based  on  317 
cases  that  were  observed  in  Schede's  clinic.  A  much  larger 
number  of  cases,  comprising  the  statistics  of  Jaffe,  Schmalfuss, 
Billroth,  and  Menzel,  is  given  by  Cheyne  (British  Medical  Jour- 
nal, April  25,  1891,  p.  898),  who  added  to  these  602  other 
cases.  He  gives  the  following  topographical  distribution  of 
tubercular  affections  of  bones  and  joints : — 

Bone  or  Joint  Affected.  Per  cent. 

Spine, 23.2 

Knee-joint, .        .  16.5 

Hip-joint,          .         ...        .        .        .        .        .  14.6 

Tarsus  and  ankle,     ........  14.4 

Elbow-joint .        .      6.3 

Wrist  and  hand,        .        .        .        ...        .        .6.0 

Skull  and  face, 5.5 

Sternum,  clavicle,  and  ribs, ^      5.2 

Pelvis, 3.5 

Femur,  tibia,  and  fibula, 3.5 

Shoulder, 1.5 

Scapula,  ulna,  and  radius, 1.0 

Humerus,      .   :*. 0.8 

Patella 0.1 

According  to  this  table  the  vertebrae  are  the  most  frequent 
seat  of  tuberculosis  of  all  bones.  Of  the  large  joints,  according 
to  the  same  author,  the  order  of  frequency  is  as  follows :  Knee- 
joint,  16.5;  hip-joint,  14.6;  tarsus  and  ankle,  14.4;  elbow- 


TYPOGRAPHY   OF   BONE   AND   JOINT   TUBERCULOSIS.  67 

joint,  6.3;  wrist  and  hand,  6  ;  and  shoulder-joint,  1.5.  A  vast 
amount  of  material  illustrative  of  the  number  of  cases  of  joint 
affections  requiring  resection,  and  showing  the  relative  number 
of  the  large  joints  involved,  is  furnished  by  Culbertson.  This 
author,  in  an  encyclopedic  work  on  the  subject  of  resection, 
gives  3908  cases  of  excision  of  the  larger  joints.  Of  this  num- 
ber, 596  cases  belonged  to  the  hip-joint,  745  to  the  knee,  326  to 
the  ankle,  984  to  the  shoulder,  1079  to  the  elbow,  and  182  to  the 
wrist.  As  this  table  includes  resections  for  gunshot  wounds, 
compound  fractures  and  dislocations,  and  other  forms  of  trau- 
matism,  it  does  not  furnish  any  accurate  information  concerning 
the  relative  number  of  operations  done  on  different  joints  for 
tubercular  affections. 

The  two  infective  diseases  which  attack  the  bones  most 
frequently  are  acute  suppurative  osteomyelitis  and  tubercular 
osteomyelitis,  and  in  reference  to  their  location  and  pathological 
anatomy  they  present  a  series  of  analogies.  In  other  respects 
they  differ  widely.  Acute  osteomyelitis  attacks  in  preference 
the  shaft  of  the  long  bones,  while  the  tubercular  form  remains 
limited  to  the  epiphysial  extremities,  as  a  rule,  and  frequently 
starts  in  the  short  and  flat  bones  that  are  not  often  the  seat  of 
primary  acute  osteomyelitis.  Lesions  occur  in  acute  osteomye- 
litis which  are  common  to  the  tubercular  variety,  and  both 
forms  are  equally  prone  to  cause  secondary  joint  diseases.  The 
apophyses  are  more  frequently  affected  by  acute  osteomyelitis 
than  the  shaft  by  tubercular  osteomyelitis,  with  the  exception 
of  the  cases  of  multiple  miliary  tubercles  in  the  medulla  of  the 
long  bones,  which  is  found  occasionally  in  the  bodies  of  persons 
who  have  died  of  general  miliary  tuberculosis.  Extensive 
tubercular  disease  of  the  marrow  and  shaft  of  the  long  bones 
is  so  exceedingly  rare  that  the  post-mortem  room  and  operations 
on  bones  and  joints  will  furnish  hundreds  of  cases  of  limited 
tuberculosis  of  bone  to  one  in  which  the  shaft  is  extensively 
infiltrated.  The  favorite  anatomical  locations  for  tubercular 
affections  of  bone  are  in  the  epiphysial  regions  of  the  long 


68  TUBERCULOSIS   OF   THE    BONES    AND   JOINTS. 

bones  and  in  the  spongy  bones,  and  only  in  exceptional  cases 
are  the  shaft  and  central  medullary  tissue  involved.  To  this 
rule  the  phalanges  of  the  hands  and  feet  furnish  an  exception, 
as  in  these  bones  a  diffuse  central  tubercular  osteomyelitis, 
known  as  spina  ventosa,  is  quite  a  common  affection. 


CHAPTER   IX. 

BONE  TUBERCULOSIS. 

Pathology  and  Morbid  Anatomy. — Some  of  the  ancient 
authors  were  well  aware  of  the  frequency  with  which  primary 
bone  affections  precede  the  development  of  joint  disease.  Mr. 
Lloyd  ("  On  the  Nature  and  Treatment  of  Scrofula,"  p.  1 20) 
says :  "  It  often  happens  that  the  whole  of  the  cancelli  are 
nearly  filled  with  this  cheesy  matter,  or  that  several  of  the  cellu- 
lar partitions  being  broken  down,  a  large  mass  of  it  is  collected 
at  one  spot,  while  the  rest  of  the  cancelli  remain  entire,  and  are 
partly  filled  with  the  yellow  fluid  ;  while  many  of  them  may 
appear  altogether  empty,  not  even  containing  any  of  their 
natural  secretion.  Sometimes  we  find  that  only  a  part  of  the 
cancellous  structure  of  the  head  of  the  bone  has  undergone 
this  change.  Indeed,  I  am  inclined  to  believe  that  it  often 
begins  in  the  centre,  as  I  have  found  the  deposition  of  the  new 
matter  is  very  frequently  greater  there,  and  the  exterior  of  the 
bone  remains  hard,  as  has  been  observed  by  Wiseman ;  while 
the  interior  is  completely  deprived  of  its  earth,  and  so  soft  as  to 
be  readily  cut  with  the  knife."  Albers  ("  Preisfrage  worin 
besteht  eigentlich  das  Uebel,  das  unter  dem  Sogenannten  frey- 
willigen  Hinken  der  Kinder  bekannt  ist  1 "  Beantworted  von 
J.  A.  Albers,  Wien,  1807)  expresses  his  convictions  on  this 
point  as  follows :  "  I  was  a  long  time  uncertain  whether  really 
the  bones,  as  Ford  asserts,  were  the  parts  first  affected  in  this 
complaint  (hip  disease).  But,  partly  through  the  excellent 
work  of  Doerner,  and  partly  through  the  opportunity  of  open- 
ing a  body  in  the  first  stage  of  the  disease,  I  felt  myself  com- 
pelled to  adopt  that  opinion.  I  found,  for  instance,  an  exten- 
sive destruction  of  the  edge  of  the  acetabulum,  while  the  other 
parts  of  the  hip-joint,  viz.,  the  cartilages,  with  the  exception  of 
a  yellow  spot,  had  suffered  little  or  nothing." 

Rust  ("Arthrokakologie  oder  Ueber  die  Verrenkungen, 

(69) 


70  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

durch  innere  Bedingungen,"  etc.,  Wien)  says:  "  I  believe  that  this 
disease  has  its  origin  in  a  morbid  state  of  the  head  of  the  femur, 
and  that  the  diseased  appearances  in  the  other  parts  of  the 
joint  are  to  be  considered  as  the  effect  of  the  previously  exist- 
ing mischief  of  the  head  of  the  bone." 

Benjamin  Brodie  is  also  of  the  opinion  that  in  strumous 
constitutions  the  disease  commences  in  the  cancellated  structure 
of  the  bone,  and  that  the  affection  of  the  cartilages  and  synovial 
membrane  is  secondary  in  the  order  of  attack.  Even  among  the 
comparatively  modern  writers  tuberculosis  of  bone  was  con- 
sidered a  rare  affection,  and  most  of  the  chronic  inflammatory 
conditions  were  regarded  as  one  of  the  many  manifestations  of 
scrofula  or  struma. 

Ried,  in  his  classical  work  ("Die  Resectionen  der  Knochen," 
etc.,  1847,  p.  79),  makes  a  sharp  distinction  between  scrofulous 
and  tubercular  caries,  and  informs  us  that,  of  the  many  cases  of 
bone  disease  that  came  under  his  observation,  he  saw  only  four 
cases  in  which  he  found  tubercles.  He  places  great  stress  on 
the  importance  of  making  a  distinction  between  the  two  varieties 
of  caries  which  he  described,  as  in  the  tubercular  form  he  be- 
lieves resection  is  not  a  justifiable  procedure.  Stanley  ("A 
Treatise  on  Diseases  of  the  Bones."  London,  1849)  speaks  of 
a  scrofulous  inflammation  as  preceding  tuberculosis,  and  states 
that  a  favorable  prognosis  should  only  be  given  before  the 
tubercular  stage  has  arrived,  as  after  that  time  the  affected  bone 
necessarily  undergoes  destructive  changes.  He  had  noticed 
the  existence  of  masses  of  chalk-like  substance  in  the  cancellous 
texture  of  bone;  but  did  not  interpret  this  morbid  appearance 
in  the  way  that  Rokitansky  has,  by  regarding  the  cretaceous 
mass  as  the  result  of  the  metamorphosis  of  tubercle  in  bone, 
analogous  to  the  change  it  undergoes  in  other  organs  and  tissues. 
Only  a  few  cases  had  come  under  his  observation  in  which  he 
could  satisfy  himself  as  to  the  co-existence  of  tubercular  affec- 
tions of  bone  and  pulmonary  phthisis. 

Even  as  late  as  1859,  Mr.  Bryant  ("On  the  Diseases  and 


BONE   TUBERCULOSIS.  71 

Injuries  of  the  Joints,"  p.  72.  London,  1859)  wished  to  ex- 
clude as  strumous  or  tubercular  all  lesions  in  bone  in  which  the 
inflammatory  product  did  not  consist  of  caseous  material,  as  ap- 
pears from  the  following:  "I  cannot  for  one  moment  doubt 
that  the  majority  of  the  cases  which  are  described  by  surgeons 
as  strumous  or  scrofulous  disease  of  a  joint,  and  of  the  articular 
extremities  of  the  bones,  depend  upon  a  chronic  inflammation  in 
the  bone.  The  disease  is,  in  its  origin  and  progress,  inflamma- 
tory, and  by  early  treatment  may  be  arrested.  The  pathologi- 
cal conditions  found  upon  examination  are  those  which  an 
inflammatory  cause  will  produce,  and  it  is  quite  exceptional  to 
find  in  any  bone  that  yellow,  cheesy  material  which  pathologists 
so  well  know  as  strumous  deposit.  I  do  not  deny  that  such  a 
deposit  may  be  occasionally  present,  but  the  cases  in  which  it  is 
found  are  so  rare  that  we  may  fairly  regard  such  a  specimen  as  a 
pathological  curiosity.  If,  then,  we  confine  the  term  "  strumous 
disease  of  bone,"  as  I  believe  we  should,  to  such  instances  only 
where  such  a  deposit  is  present,  as  surgeons,  we  shall  seldom 
have  occasion  to  employ  it." 

Koster's  ("Ueber  locale  Tuberculose."  Centralblatt  f.  d. 
Ned.  Wissenschaften,  No.  58,  1873)  researches  shed  a  flood  of 
light  on  the  pathology  and  morbid  anatomy  of  chronic  inflam- 
matory affections  of  bone.  He  showed  that  miliary  tubercles 
could  not  only  be  constantly  found  in  the  fungous  granulations 
in  diseased  joints,  but  that  they  could  be  seen  with  equal 
regularity  in  the  granulation  masses  in  bone,  tendon-sheaths, 
and  bursa3,  and  later  he  added  caseous  ostitis,  osteomyelitis,  and 
caries. 

In  this  country,  H.  H.  Smith  (  Transactions  of  the  Ameri- 
can Medical  Association,  1879)  was  one  of  the  first  to  call  at- 
tention to  the  fact  that  most  cases  of  chronic  osteomyelitis  are 
of  a  tubercular  nature.  He  pointed  out  the  influence  of  con- 
gestion of  the  medulla  on  cell-proliferation  and  on  the  increased 
number  of  leucocytes,  also  the  defective  elaboration  of  blood  as 
a  result  of  perverted  myeloid  collection,  and  arrived  at  the  con- 


72  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

elusion  that  struma  and  tubercle  are  so  closely  allied  that  their 
differences  cannot  well  be  demonstrated. 

Tuberculosis  of  Bone  a  Specific  Form  of  Chronic  Osteo- 
myelitis.— The  tubercle  bacillus  has  a  special  predilection  for 
the  medullary  tissue  of  the  bones,  and  especially  for  the  red 
medullary  tissue  in  the  cancellated  tissue  in  the  region  of  the 
epiphysial  cartilage  of  the  long  bones  and  some  of  the  short 
bones,  notably  the  vertebrae  and  the  carpal  and  tarsal  bones. 
As  an  inflammatory  affection  it  is  more  correct  to  speak  of 
tubercular  osteomyelitis  than  ostitis,  since  the  medullary  tissue 
and  the  blood-vessels  ivhich  it  contains  are  ilie  jiarts  that  take  an 
active  share  in  the  inflammatory  process.  In  his  experiments  on 
animals,  made  for  the  purpose  of  studying  the  initial  pathologi- 
cal changes  in  bone  the  seat  of  an  active  inflammation,  F.  Busch 
(•'  Ueber  die  Veranderungen  des  Marks  der  langcn  liohren- 
knochen  bei  experimentell  erregter  Entzundung  eines  dersel- 
ben."  Berl.  klin.  Wocheuschrift,  No.  13,  1874)  found,  as  the 
first  histological  changes,  the  medulla  hyperaemic  and  an  ac- 
cumulation of  lymphoid  cells.  In  the  red  marrow  he  found, 
under  the  microscope,  an  aggregation  of  round,  colorless  cells, 
containing  a  large  nucleus,  but  no  nucleated  red  blood-cor- 
puscles. These  cells  were  evidently  embryonal  medullary  cells, 
— the  product  of  tissue-proliferation  from  the  fixed  myeloid  cells. 
The  bone-cells  take  an  active  part  in  tubercular  inflammation  of 
bone,  and  it  is  therefore  not  proper  to  speak  of  the  affection  as 
an  ostitis.  The  anatomical  conditions  of  the  vessels  in  the  epi- 
physial region  of  the  long  bones  in  young  persons,  and  in  the 
vessels  of  the  medidlary  tissue,  favor  implantation  of  floating 
tubercle  bacilli  upon  the  inner  surface  of  the  vessel-wall,  and 
they  also  explain  the  frequency  with  ichich  localization  of  the 
tubercular  process  takes  place  in  this  locality.  The  shaft  of  the 
long  bones  is  peculiarly  exempt  from  tubercular  disease,  with 
the  exception  of  the  phalanges  of  the  fingers  and  toes  and  the 
metacarpal  and  metatarsal  bones  in  children,  where  the  tubercu- 
lar osteomyelitis  gives  rise  to  the  well-known  spina  ventosa  of 
the  old  authors. 


BONE   TUBERCULOSIS.  73 

Pathological  Varieties  of  Tubercular  Osteomyelitis. — The 
same  cause — the  bacillus  of  tuberculosis — produces  different 
forms  of  tubercular  osteomyelitis  according  to  the  method  of 
infection,  the  number  of  foci,  the  anatomical  location,  the 
extent  of  the  inflammation,  and  the  stage  of  the  disease. 

Miliary  Tuberculosis. — This  form  of  tubercular  osteomye- 
litis is  not  of  much  interest  to  the  surgeon,  as  it  seldom  occurs 
as  an  independent  affection,  being  usually  associated  with  gen- 
eral tuberculosis.  Circumscribed  miliary  tuberculosis  often 
occurs  in  the  periphery  of  older  foci,  and  this  is  more  especially 
the  case  if  the  primary  product  has  undergone  caseation,  and 
the  tissues  around  the  cheesy  mass  are  not  protected  by  an 
impermeable  wall  of  granulation  tissue.  The  miliary  nodules 
in  bone,  when  found  as  a  part  of  general  miliary  tuberculosis, 
present  the  same  typical  structure  as  in  other  organs.  The 
nodules  are  arranged  in  groups  in  certain  parts  of  the  bone 
predisposed  to  tuberculosis,  or  they  may  be  disseminated 
throughout  the  entire  bone.  Lazarus  has  recorded  five  cases  of 
acute  general  tuberculosis  in  which  the  bones  were  examined 
with  positive  results.  Miliary  tubercles  have  been  found  in  the 
sternum  and  ribs  in  post-mortem  examinations  of  cases  of 
pulmonary  phthisis  in  the  absence  of  general  tuberculosis. 

Fungous  Osteomyelitis. — If  the  tubercular  inflammation 
from  the  beginning  involve  only  a  limited  area  of  bone- tissue, 
the  specific  product  is  granulation  tissue.  This  form  has  been 
described  by  Konig  as  granulating  focus.  The  process  is  an 
exceedingly  slow  one,  and  necrosis  of  the  cancellated  bone  is 
either  wanting  or  the  particles  of  necrosed  bone  are  so  small 
that  it  often  requires  the  aid  of  a  microscope  to  detect  them. 
The  granulating  focus  is  found  as  single  or  multiple,  round  or 
oval  spaces,  from  the  size  of  a  millet-seed  to  that  of  a  pea  or 
hazel-nut,  filled  with  granulation  tissue,  in  which  are  often 
found  imbedded  minute  spiculae  of  bone.  Histologically,  the 
granulation  tissue  is  composed  of  the  same  cell-elements  as 
recent  tubercle  in  other  organs,  only  that,  as  a  rule,  the  giant- 


74  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

cells  are  more  numerous  and  of  larger  size.  Direct  infection 
of  bone  is  an  extremely  uncommon  occurrence  ;  consequently, 
bone  tuberculosis  must  be  regarded  clinically  as  a  secondary 
lesion  caused  by  an  embolic  infection  from  an  older  tubercular 
focus  in  some  other  organ.  As  soon  as  embolic  infection  in 
bone  has  taken  place,  a  process  of  osteoporosis  and  decalcifica- 
tion  occurs  around  the  tubercular  embolus  or  thrombus,  and  the 


FIG.  15.— TYPICAL  GRANULATION  TUBERCULOSIS  OF  BONE  WITH  MANY 
ROUND  AND  OBLONG  TUBERCLES  AND  WITH  STRIPES  OF  TUBERCULAR 
TISSUE,— TUBERCLE  TISSUE.  (Konig.) 

pre-existing  medullary  and  connective  tissues  are  transformed 
into  embryonic  or  granulation  cells,  which  impart  to  the  prod- 
uct of  the  specific  inflammation  its  characteristic  appearance. 
According  to  Kiener  and  Poulet  ("  De  Posteoperiostite  tubercu- 
leaux  chronique  ou  carie  des  os."  Archiv  de  Phys.  normal  et 
path.,  3  series,  tome  i,  p.  224),  rarefaction  of  the  bone  around 
a  tubercular  focus  takes  place  in  two  different  ways, — either  in 
the  usual  manner,  by  the  formation  of  Howship's  lacunae,  or  by 


BONE   TUBERCtfLOSlS.  75 

liquefaction  and  disappearance  of  the  cement-substance,^after 
the  bone  has  previously  presented  a  vitreous  appearance.  It  is 
not  often  that  only  a  single  focus  of  tubercular  infection  in  bone 
is  present ;  more  frequently  two  or  three  foci  appear  in  the  same 
region  simultaneously,  or  in  slow  or  rapid  succession,  and  it  is 
not  unusual  to  find  that,  two  neighboring  epiphyses  are  infected 
at  the  same  time  or  during  the  course  of  the  disease.  Under 
favorable  circumstances  the  granulations  remain  for  an  indefi- 
nite period  of  time  without  undergoing  caseation.  As  long  as 
decalcification  of  the  surrounding  bone  goes  on  the  infection  is 
progressive,  but  as  soon  as  the  zone  of  granulation  tissue 
around  the  infected  focus  is  transformed  into  bone,  osteosclero- 
sis  takes  place,  and  the  tubercular  process,  for  the  time  being  at 
least,  becomes  arrested ;  the  micro-organisms  are  shut  in,  as  it 
were,  by  an  impermeable  wall  of  sclerosed  bone.  The  grann- 
hifing  focus  ivithout  caseation  is  the  most  favorable  form  of 
tubercular  osteomyelitis,  often  resulting  in  a  spontaneous  cure, 
and  most  amenable  to  successful  surgical  treatment.  During 
this  stage  general  tuberculosis  is  not  likely  to  occur,  as  the  liv- 
ing cells  hold  the  bacilli  in  captivity,  as  it  were,  thus  preventing 
local  and  general  dissemination. 

Caseous  Foci  in  Bone. — A  caseous  focus  in  bone  only  indi- 
cates the  site  of  a  former  fungous  osteomyelitis,  and  we  often 
meet  with  these  two  conditions  side  by  side, — a  zone  of  tuber- 
cular osteomyelitis  around  a  cheesy  centre. 

Cheesy  tubercular  cavities  in  bone  resemble  the  same  con- 
dition in  the  lungs,  only  that  secondary  infection  with  pus- 
microbes  is  of  less  frequent  occurrence,  and  on  this  account  the 
cavity  never  attains  such  large  size  as  in  the  latter  organ.  If 
the  cavity  is  larger  than  a  hazel-nut  it  usually  contains  a  seques- 
trum of  considerable  size.  If  such  a  cavity  is  exposed  in  a 
fresh  specimen  by  a  transverse  section  through  the  bone  it's 
interior  presents  appearances  according  to  the  stage  the  tuber- 
cular process  has  reached.  If  caseation  has  not  advanced  far  it 
contains  grayish-red  granulations,  or  the  granulations  present  a 


76 


TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 


yellowish-gray  color  if  caseation  is  well  marked,  or  the  cavity  is 
filled  with  a  cheesy  mass  when  this  degenerative  process  has 
been  completed.  If  the  contents  of  such  a  cavity  are  rubbed 
between  the  fingers  minute  particles  of  bone  can  usually  be 
detected  in  this  manner.  If  these  particles  are  too  small  to  be 
recognized  by  the  sense  of  touch  or  sight  their  presence  can 
almost  always  be  demonstrated  by  microscopical  examination. 
In  other  cases  larger  sequestra  are  imbedded  in  the  cheesy 

material,  and  in  some  a  large 
sequestrum  occupies  almost 
the  entire  cavity,  being  sepa- 
rated from  the  walls  by  a 
thin  layer  of  granulation 
tissue.  The  color  of  the 
dead  bone,  owing  to  the 
presence  of  cheesy  material 
in  its  meshes,  corresponds 
with  that  of  the  surround- 
ing soft  mass.  If  the  wall 
of  the  cavity  is  soft  it  usu- 
ally, although  not  always, 
denotes  that  the  disease  is 
in  an  active  state.  As  soon 
as  the  inflammatory  process 
has  subsided  the  osteoporo- 
tic  bone  becomes  sclerosed, 
and  the  tubercular  material 

is  walled  in  and,  for  the  time  being,  is  rendered  quite  harmless. 
If,  in  the  former  instance,  the  contents  of  the  cavity  are  removed 
with  a  sharp  spoon,  the  inner  portion  of  the  wall  comes  away 
with  the  infected  tissue,  the  line  of  demarcation  between  healthy 
and  diseased  tissue  not  being  very  well  defined  ;  while  in  the 
latter  cases  the  infected  material  can  be  thoroughly  removed  by 
the  same  procedure  without  removing  a  portion  of  the  wall  of 
the  cavity.  In  the  latter  instance  the  sclerosis  of  the  wall  of  the 


FIG.  16.— UPPER  PORTION  OF  FEMUR  OF  BOY 
Six  YEARS  OLD  WHO  DIED  OF  GENERAL,  TUBER- 
CULOSIS. Natural  Size.  (Krause.) 

a,  cheesy  focus  in  head  of  femur;  b  ft,  infiltration  of  cancel- 
lated tissue,  extending  from  focus  to  shaft  of  femur ;  d,  defect 
of  head  of  femur,  caused  by  pressure  against  acetabulum,  which 
resulted  in  subluxation. 


BONE   TUBERCULOSIS.  77 

cavity  indicates  that  the  healing  process  has  been  completed,  or 
at  least  is  progressing  favorably.  The  wall  of  the  cavity  is 
usually  lined  with  granulation  tissue  containing  the  characteristic 
histological  elements  of  tubercle,  and  if  the  wall  is  osteoporotic 
it  usually  is  also  infiltrated  with  tubercle.  (Fig.  16,  b  5.)  The 
more  advanced  the  retrograde  changes,  the  less  marked  the  histo- 
logical structure  of  the  inflammatory  product.  In  case  caseation 
has  far  advanced  the  microscope  shows  only  granular  detritus, 
and  the  contents  of  the  cavity  are  no  longer  connected  with  the 
inner  surface  of  the  wall.  Cheesy  foci  are  frequently  found  in 
the  epiphysial  extremities  of  the  long  bones  entering  into  the 
formation  of  a  tubercular  joint.  The  number  of  such  foci  varies 
from  one  to  seldom  more  than  three  in  one  articular  extremity. 
They  are  also  frequently  met  with  in  the  bodies  of  the  vertebrae. 
As  in  other  localities,  caseation  in  osseous  foci  always  commences 
in  the  centre  and  extends  toward  the  periphery.  Numerous 
caseous  centres  in  different  portions  of  the  infected  area  become 
confluent  and  form  large  masses.  Near  the  deposit  in  some 
specimens  it  can  be  seen  that  the  trabeculse  are  thickened,  and 
some  of  the  cancellous  spaces  have  lost  their  fat-cells  and  are 
occupied  by  a  semi-fibrous  material  resembling  the  pathological 
product  in  some  forms  of  synovial  tuberculosis.  In  this  form  of 
bone  tuberculosis  plastic  periostitis  in  the  vicinity  of  the  foci  is 
not  well  marked.  The  granulation  tissue,  which  is  the  charac- 
teristic product  of  the  tubercular  inflammation,  absorbs  the  bone 
with  which  it  comes  in  contact,  and  thus  makes  room  for  the 
inflammatory  product.  The  gradual  substitution  of  granulation 
tissue  for  bone  explains  the  absence  of  intra-osseous  tension, 
which  is  one  of  the  prominent  conditions  in  acute  suppurative 
osteomyelitis.  As  the  tubercles  infiltrate  the  surrounding  bone- 
tissue  the  lacunar  absorption  covers  a  larger  field,  while  casea- 
tion extends  from  the  centre  of  the  infected  area  from  different 
points.  In  some  cases  the  tubercular  process  is  more  rapid,  and 
time  is  not  afforded  for  total  absorption  of  the  trabeculse  by  the 
granulations  before  caseation  is  complete ;  hence,  we  find  in 


78  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

such  specimens  minute  particles  of  necrosed  bone.  Sequestra 
imbedded  in  cheesy  material  remain  unchanged  in  size,  as  their 
diminution  in  size  or  complete  removal  by  absorption  can  only 
take  place  as  long  as  they  are  in  contact  with  and  are  acted 
upon  by  living  granulation  tissue. 

The  pathologico-anatomical  diagnosis  of  these  osseous  foci 
is  rendered  more  difficult  by  the  occurrence  of  small  foci  in  the 
apophyses  which  are  occasionally  found  in  acute  osteomyelitis. 
For  the  expert,  however,  the  macroscopical  evidences  are  suffi- 
cient upon  which  to  base  a  differential  diagnosis.  The  resem- 
blance consists  only  in  the  form  and  location  of  the  foci,  while 
the  contents  present  characteristic  peculiarities  in  both  forms. 
In  acute  osteomyelitis  the  foci  contain  flabby  granulations  and 
pus ;  usually,  also,  small  sequestra  of  a  yellow  color.  If  the 
pus  in  old  cases  become  inspissated,  it  may  present  some 
resemblance  to  tubercular  material,  but  is  of  an  entirely  differ- 
ent appearance.  The  pus  is  of  the  color  and  consistence  of 
cream ;  or,  if  inspissation  has  advanced  further,  it  bears  a 
strong  resemblance  to  moist,  unslacked  lime.  In  the  granula- 
tions no  tubercles  can  be  found.  If  the  disease,  spontaneously 
or  by  appropriate  treatment,  come  to  a  stand-still  before  it  has 
implicated  an  adjacent  joint  or  resulted  in  the  formation  of  a 
tubercular  abscess,  the  granulations,  if  they  have  not  undergone 
caseation,  may  become  transformed  into  connective  tissue  or 
bone,  and  the  patient  recovers  not  only  the  function  of  the  part 
affected,  but  is  protected  against  local  and  general  infection 
from  this  source.  If  caseation  has  occurred,  a  spontaneous 
cure  under  such  circumstances  is  still  possible  by  encapsulation, 
calcification,  and  the  formation  of  a  wall  of  dense  bone  around 
the  area  of  infection.  Nelaton  has  given  an  excellent  descrip- 
tion of  encapsulation  of  tubercular  foci  in  bone.  If  the  disease 
show  no  tendency  to  limitation,  the  tubercular  product  under- 
goes the  typical  pathological  changes, — coagulation  necrosis, 
caseation,  and  liquefaction  of  the  cheesy  material.  If  it  travel 
in  the  direction  of  a  joint,  it  involves  the  latter  as  soon  as  per- 


BONE.  TUBERCULOSIS. 


79 


foration  takes  place.  The  escape  of  tubercular  material  into  a 
joint  is  followed,  as  a  rule,  by  diffuse  tubercular  arthritis,  the 
bone  affection  giving  rise  to  an  inflammation  of  the  joint  iden- 
tical in  character  with  the  primary  bone-lesion,  the  primary 
disease  and  the  complication  being  known  as  tubercular  osteo- 
arthritis.  If  the  joint  escape  and  the  disease  extends  toward 
the  periphery,  it  finally  reaches  the  periosteum,  causing  a  tuber- 


FIG.  17. —  LOWER  ARTICULAR  EXTREMITY  OF  FEMUR  WITH  CHEESY 
FOCUS,  WHICH  AT  a  HAS  REACHED  THE  SURFACE  OUTSIDE  THE  INSERTION 
OF  THE  SYNO VIAL  MEMBRANE.  JOINT  NOT  AFFECTED.  (Kbnig.) 

cular  periostitis,  and  finally  appears  on  the  surface  as  a  tuber- 
cular abscess.  Perforation  of  the  periosteum  often  takes  place 
close  to  the  insertion  of  the  capsular  ligament  of  the  adjacent 
joint ;  the  joint  escapes  by  the  interposition  of  only  a  few  lines 
of  healthy  tissue  between  it  and  the  infected  route  along  which 
the  inflammatory  product  travels  toward  ilie  surface. 

Although  the  joint  may  at  first  escape  infection  by  the 
tubercular  abscess  traveling  in  this  direction,  it  often  becomes 


80  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

involved  later  by  the  disease  attacking  the  capsule,  and  finally 
the  synovial  membrane.  The  extension  of  the  bone  disease  to 
the  joint  by  this  indirect,  circuitous  route  is  a  very  rare  occur- 
rence, as  compared  with  direct  infection  by  perforation  of  an 
osseous  focus  into  adjacent  joint. 

Tubercular  Necrosis. — By  tubercular  necrosis  is  not  meant 
that  form  of  bone  tuberculosis  in  which  death  of  minute  par- 
ticles of  bone  occurs  as  one  of  the  consequences  of  tubercular 
osteomyelitis,  but  in  which  necrosis  of  a  fragment  of  bone  of 
considerable  size  takes  place  as  one  of  the  early  effects  of  the 
tubercular  inflammation.  Tubercular  necrosis,  especially  in  its 
most  characteristic  forms,  is  an  entirely  different  condition  from 
tubercular  granulating  foci.  It  also  differs  materially  from 
acute  necrosis,  which  is  caused  by  suppurative  osteomyelitis,  as 
the  sequestrum  remains  for  a  longer  time  in  connection  with 
the  surrounding  tissues.  It  also  differs  from  it  in  regard  to  the 
location  of  the  sequestrum,  as  in  the  acute  form  the  shaft  is 
usually  affected,  while  the  tubercular  variety  is  found  almost 
exclusively  in  the  epiphyses  of  the  long  bones  and  the  short 
and  flat  bones.  The  sequestrum  is  also,  as  a  rule,  smaller,  and 
consists  of  cancellated  bone-tissue.  The  common  articular 
sequestrum  is  seldom  larger  than  a  pigeon's  egg.  It  is  occa- 
sionally derived  from  the  surface  of  a  bone ;  but  more  fre- 
quently it  is  in  the  interior  of  the  bone,  and  very  often  in  the 
epiphyses  of  the  long  bones.  It  is  wedge-shaped,  the  base  of 
the  wedge  being  directed  toward  the  articular  surface,  and  the 
apex  toward  the  medullary  cavity. 

Tubercular  necrosis  necessarily  follows  if  the  infected  area, 
from  the  beginning,  exceed  the  size  of  a  hazel-nut.  The  non- 
vascularity  of  the  tubercular  product  and  the  blocking  and 
destruction  of  blood-vessels,  during  the  early  stages  of  the 
inflammation,  determine  early  death  of  the  bone,  corresponding 
in  extent  to  the  limits  of  the  inflammation,  and  if  this  exceed 
the  resorption  capacity  of  the  granulations  the  dead  tissue  is 
not  removed  by  absorption,  and  is  found  as  a  sequestrum  as 


BONE    TUBERCULOSIS. 


81 


soon  as  it  has  become  detached  from  the  surrounding  healthy 
bone.  The  density  of  the  dead  bone  is  very  variable,  in  some 
less  than  that  of  normal  bone ;  in  others  it  resembles  compact 
bone.  If  the  tubercular  process  has  been  rapid,  and  the  granu- 
lation tissue  is  scanty,  the  necrosed  bone  is  not  osteoporotic ; 
but  if  the  disease  has  pursued  a  more  chronic  course,  and  has 
resulted  in  the  production  of  an  abundance  of  granulation 
tissue,  it  presents  a  honey-combed  appearance,  is  irregular  in 


FIG.  18. — WEEGE-SHAPED  TUBERCULAR  SEQUESTRUM  IN  THE  HEAD  OF 
THE  TIBIA.  BONE  AND  SEQUESTRUM  DIVIDED  LONGITUDINALLY.  BASE  OF 
SEQUESTRUM  EXTENDING  INTO  JOINT.  (Kijnig.) 

shape  and  variable  in  size,  and  does  not  correspond  with  the 
area  of  the  infected  district,  as  part  of  it  has  been  absorbed  by 
the  granulations.  In  shape  the  tubercular  sequestra  are  irregu- 
lar, quadrilateral,  or  wedge-shaped,  according  to  the  structure 
of  bone  involved,  the  method  of  infection,  the  length  of  time 
which  has  elapsed,  and  the  nature  of  its  immediate  surroundings. 
The  cancellous  spaces  are  filled  with  the  products  of  tubercular 
inflammation  in  different  stages  of  degeneration.  The  color  of 


82 


TUBERCULOSIS   OF    THE    BONES    AND    JOINTS. 


the  necrosed  bone  depends  on  the  condition  of  the  granulations 
which  surround  it ;  if  these  have  not  undergone  secondary  de- 
generative changes  it  may  resemble  healthy  bone,  but  if  casea- 
tion  has  taken  place  it  is  infiltrated  with  the  cheesy  material, 
and  then  presents  a  grayish-yellow  or  yellow  appearance.  If 
the  dead  bone  has  undergone  no  reduction  in  size,  and  the 
granulations  surrounding  it  are  few,  it  remains  firmly  wedged 
in  position,  and  under  such  circumstances  it  is  often  difficult  to 
locate  the  exact  boundary-line  between  it  and  the  surround- 
ing healthy  bone  or  dislodge  it  from  its  incarcerated  position. 
Konig  has  described  a  form  of  necrosis  of  the  articular  extremi- 
ties of  the  long  bones,  as  a  distinct 
variety,  under  the  name  of  tuber- 
cular infarct.  According  to  Konig, 
such  an  infarct,  like  infarcts  in 
other  tissues  and  organs,  is  always 
caused  by  impaction  of  an  embolus 
in  one  of  the  distal  arterial  branches, 
and  presents  the  same  wedge-shaped 
appearance  and  peripheral  zone  of 


FIG.  19. — RESECTED  UPPER  END 
OF  FBMUK  FROM:  A  GIRL  FIVE  YEARS 
OLD.  Natural  size.  (Krause.) 

Large,  wedge-shaped,  subohondral  sequestrum 
in  head  of  femur,  partially  detached  by  tubercular 
granulations,  articular  cartilage  elevated  from 
base  of  sequestrum. 


congestion. 


In  some  cases  the  articular 
cartilage  is  destroyed  and  the  base 
of  the  sequestrum  projects  into  the  joint,  and  if  the  joint  has 
still  been  used  the  surface  of  the  bone  presents  a  polished 
surface.  Cheyne  does  not  agree  with  Konig  in  the  etiology  of 
this  form  of  bone  tuberculosis,  because,  as  he  maintains,  the 
dead  bone  shows  invariably  evidences  of  an  antecedent  inflam- 
mation. He  asserts  that  certain  areas  of  bone-tissue  are  de- 
stroyed by  the  tubercular  inflammation,  and  that  sequestration 
always  takes  place  by  the  absorption  of  trabeeulae  in  the  pe- 
riphery of  the  necrosed  bone.  That  a  fragment  of  tubercular 
tissue  impacted  in  a  small  artery  may  be  the  cause  of  a  tuber- 
cular necrosis  has  been  shown  experimentally  by  Miiller.  That 
tubercular  necrosis,  like  other  forms  of  bone  tuberculosis.,  is 


BONE   TUBERCULOSIS.  83 

usually  associated  with  antecedent  tubercular  foci  is  well  known. 
If  a  minute  fragment  of  tubercular  tissue  should  reach  the 
general  circulation,  localization  would  most  frequently  occur  in 
the  tissues  and  vessels  predisposed  to  such  an  occurrence,  and 
this  is  notably  the  case  in  the  medullary  tissue  and  blood-vessels 
in  the  epiphysial  region  of  the  long  bones  in  children  and 
young  adults.  The  size  of  the  vessel  obstructed  by  an  infected 
embolus  will  determine  the  extent  of  the  necrosis.  If  the 
embolus  is  small,  the  area  of  necrosis  may  be  increased  by  the 
blocked  vessel  becoming  the  seat  of  secondary  thrombosis, 
obliteration  of  the  vessel  taking  place  in  a  proximal  direction 
by  growth  of  the  thrombus  toward  the  heart.  The  common 
articular  sequestrum  is  seldom  larger  than  a  pigeon's  egg.  As 
the  cortical  portion  of  bone  is  seldom  involved  by  a  tubercular 
infarct,  the  necrosed  area  is  often  overlooked  in  operations  on 
tubercular  joints  unless  the  bone  is  sawn  through.  In  the  living 
bone  it  is  sometimes  very  difficult  to  demonstrate  the  presence 
and  contour  of  the  sequestrum,  so  small  are  the  differences  be- 
tween the  dead  and  living  bone;  we  often  have  to  rely  on  the 
color  alone  to  determine  the  presence  and  outlines  of  the  seques- 
trum. The  dead  bone  appears  of  a  dirty-white  or  yellowish- 
white  color,  while  the  surrounding  'bone  presents  a  normal 
pinkish  hue.  If  the  dead  bone  is  scraped,  cheesy  material  is 
obtained.  The  difficulty  in  recognizing  the  dead  bone  is  often 
enhanced  by  the  density  of  the  sequestrum,  which  often  equals 
that  of  the  surrounding  healthy  bone.  In  other  cases  the 
sequestrum  appears  sclerosed,  harder  than  the  surrounding 
bone, — a  condition  which  can  only  be  explained  by  the  fact  that 
soon  after  the  commencement  of  the  disease  the  bone  around  the 
sequestrum  becomes  rarefied,  so  that  the  sequestrum  represents 
the  normal  density  of  bone,  while  the  surrounding  bone  has  be- 
come osteoporotic.  At  other  times  the  impression  is  received 
that  sclerosis  of  the  sequestrum  is  an  initial  condition  of  the 
tubercular  process. 

An  anatomical  diagnosis  is  often  a  matter  of  great  difficulty, 


84  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

as  no  line  of  demarcation  can  be  seen  separating  the  living  from 
,the  dead  bone.  Separation  of  the  sequestrum  takes  place  more 
slowly  than  after  suppurative  osteomyelitis,  the  process  requiring 
often,  according  to  the  size  of  the  sequestrum  and  the  activity 
of  the  inflammatory  process,  months  and  years  for  its  comple- 
tion. If  the  granulations  which  surround  the  sequestrum  do 
not  undergo  cheesy  degeneration  the  bone  becomes  imbedded 
and  tits  accurately  into  the  cavity,  and  if  the  surrounding  zone 
pf  granulation  is  converted  into  connective  tissue  it  may  become 
permanently  encapsulated ;  but  even  from  such  an  apparently 
healed  depot  local  and  general  infection  can  occur  at  any  time. 
Intermediary  forms  of  bone  tuberculosis  occur  between  the  gran- 
ulating foci  and  tubercular  necrosis  just  described. 

In  such  foci  the  granulations  become  gradually  more  and 
more  abundant  at  the  expense  of  the  sequestrum  or  the  sur- 
rounding osteoporotic  bone,  and  finally  the  detached  necrosed 
bone  lies  in  the  cavity,  loosely  imbedded  in  the  granulations. 
In  the  necrotic  form  of  osseous  tuberculosis  we  observe,  as  a 
rule,  more  frequently  hyperplastic  tissue-proliferation  around 
the  seat  of  inflammation  after  the  formation  of  fistulse  than  in 
the  granulating  focus.  The  microscopical  examination  in  this 
variety  of  bone  tuberculosis  presents  greater  difficulties  in  demon- 
strating the  presence  of  tubercle  bacilli  than  is  the  case  in 
fungous  osteomyelitis ;  yet,  as  a  rule,  they  can  be  found  in  the 
sequestrum  and  granulations.  In  conducting  this  method  of 
examination  it  is  necessary  that  the  bone  should  be  decalcified 
and  sections  of  it  stained  and  examined  under  the  microscope. 
In  specimens  thus  prepared  it  can  be  seen  that  the  blood-vessels 
still  exist  in  some  of  the  Haversian  canals  to  a  certain  depth  ; 
those  of  the  Haversian  canals  are  filled  with  cells  and  granular 
detritus.  Scanty  remnants  of  epithelioid  and  giant  cells  can 
also  be  found.  Such  sequestra  may  remain  in  the  place  where 
they  originated  years  alter  apparent  healing  has  taken  place, 
and  are  then  connected  with  the  surrounding  bone  by  connective 
tissue.  Konig  is  of  the  opinion  that  the  tubercular  infarct  in 


BONE   TUBERCULOSIS.  85 

bone  is  caused  by  a  tubercular  embolus  derived  from  some 
distant  antecedent  tubercular  focus,  and  that  this  plug  contains 
the  essential  cause  of  the  tubercular  process, — the  bacilli  of 
tuberculosis.  He  claims  that  necrosis  would  not  take  place  if, 
from  such  an  embolus,  bacilli  would  not  reach  the  terminal 
arterial  vessels,  causing  complete  obstruction  in  these  vessels  on 
the  distal  side  of  the  primary  obstruction.  The  extension  of  the 
disease  is  due  to  spreading  of  the  tubercular  inflammation  along 
the  course  of  the  small  vessels.  The  fate  of  the  affected  bone 
and  the  surrounding  tissue  is  variable.  Under  the  most  favor- 
able conditions  a  tubercular  focus  heals  completely.  Such,  a 
favorable  termination  can  be  expected  most  frequently  in  the 
granulating  form  of  osseous  tuberculosis.  After  the  tubercular 
granulations  have  undergone  retrograde  metamorphosis  their 
place  is  taken  by  vigorous  granulation  tissue,  which  spring  from 
the  adjacent  healthy  tissue,  and  these  are  transformed  into  con- 
nective tissue,  which,  by  growing  into  and  around  the  tubercular 
material,  gradually  takes  its  place.  Spontaneous  cure  is  often 
more  apparent  than  real,  as  some  of  the  tubercular  granulations 
remain,  and  in  such  a  partially  healed  focus  a  new  tubercular 
inflammation  may  be  lighted  up  at  any  time  under  the  influ- 
ence of  adequate  local  or  general  conditions.  Such  recidiva- 
tions  are  often  observed  in  tubercular  affections  of  the  hip-  and 
knee-  joints  after  the  original  partially  healed  affection  has 
remained  in  a  latent  condition  for  years.  Small  sequestra  are 
often  completely  removed  by  granulation  tissue  if  caseation  of 
the  tubercular  product  has  not  occurred,  but  not  infrequently  it 
is  the  case,  in  the  event  that  they  are  too  large  to  be  completely 
removed  in  this  manner,  that  they  are  rendered  innocuous  by 
becoming  permanently  imbedded  in  connective  tissue,  while 
encapsulation  of  a  large  sequestrum  never  occurs. 

Diffuse  Tubercular  Osteomyelitis. — Independently  of  gen- 
eral miliary  tuberculosis  diffuse  tubercular  osteomyelitis  is  quite 
rare.  It  occurs  more  frequently  as  a  secondary  affection  from  a 
tubercular  joint  than  as  a  primary  osseous  lesion. 


86  TUBERCULOSIS   OP   THE   BONES   AND   JOINTS. 

Kiener  and  Poulet  (pp.  cit.)  have  described  a  form  of 
secondary  tuberculosis  of  bone  with  rapid  extension  of  the  pro- 
cess. Here  the  disease  originates  in  persons  debilitated  in  con- 
sequence of  a  primary  tuberculosis  in  a  bone  that  has  already 
undergone  extensive  pathological  changes.  This  form  is  char- 
acterized by  a  tendency  to  suppuration  and  the  production  of 
fungosities  in  the  surrounding  tissues.  It  appears  under  two 
principal  varieties:  1.  Progressive  tuberculosis  with  attached 
sequestrum ;  that  is,  the  meshes  of  the  sequestrum  are  filled  with 
granulations  growing  into  them  from  the  interior  surface  of  the 
cavity ;  this  is  the  caries  fungosa  of  the  old  authors.  2.  Circum- 
scribed tuberculosis  with  small  sequestra,  surrounded  by  sup- 
purating granulations ;  by  the  rapid  extension  of  the  tubercular 
process  at  circumscribed  points  several  sequestra  are  produced 
simultaneously,  which  excite  massive  fungosities  in  their  vicinity. 
The  same  authors  describe  another  form  of  bone  tuberculosis 
which  they  term  acute  progressive  tubercular  osteomyelitis,  and 
which,  according  to  their  observation,  is  characterized  by  a 
tendency  to  early  suppuration.  This  form  is  exceedingly  rare 
and  often  involves  almost  an  entire  epiphysis,  the  analogue  of 
acute  cheesy  pneumonia.  It  resembles  closely  acute  suppurative 
osteomyelitis,  but  microscopic  examination  shows  all  the  char- 
acteristic appearances  of  tuberculosis,  condensating  and  rarefying 
osteomyelitis,  cheesy  degeneration,  and  tubercle  formation  upon 
the  blood-vessels,  production  of  small  sequestra  and  fungosities. 
The  clinical  and  pathological  characteristics  of  this  local  form  of 
bone  tuberculosis  consist  in  the  rapid  extension  of  the  affection 
and  the  danger  to  life  from  general  infection.  On  making  a 
longitudinal  section  through  a  long  bone  affected  by  diffuse 
tubercular  osteomyelitis,  we  observe  conditions  which  closely 
resemble  acute  suppurative  osteomyelitis.  We  find  large, 
irregular,  often  multiple  areas  of  a  yellowish- white  infiltration, 
with  numerous  foci  of  liquefied  cheesy  material.  The  infection 
extends  from  the  epiphyses  of  long  bones  to  the  medullary 
cavity  and  the  periosteum,  along  the  Haversian  canals  and  the 


BONE    TUBERCULOSIS.  87 

blood-vessels.  The  secondary  periostitis  caused  in  this  manner, 
as  a  rule,  assumes  a  plastic  type,  resulting  in  the  formation  of 
diffuse,  irregular  masses  of  new  bone.  In  these  cases  there  is 
no  tendency  whatever  to  limitation  in  the  formation  of  sequestra, 
but  rather  a  tendency  to  spread  indefinitely  and  to  invade  even 
the  medullary  tissue  of  the  shaft.  If  the  spongy  bones  are  the 
seat  of  this  process  the  disease  extends  with  great  rapidity,  and 
in  a  short  time  the  entire  bone  is  diffusely  infiltrated.  Patients 
suffering  from  this  rapid  form  of  tubercular  osteomyelitis  are 
exposed  to  all  the  dangers  incident  to  diffuse  general  miliary 
tuberculosis  if  the  infected  tissues  are  not  removed  by  a  timely 
and  thorough  operation.  In  operating  it  is  important  to  recog- 
nize this  form,  since  it  requires  more  radical  measures,^-either 
amputation  or  very  extensive  excision  of  the  entire  thickness  of 
the  affected  bone.  Less  heroic  local  measures,  such  as  will  meet 
the  indications  in  other  less  diffuse  varieties  of  osteotuberculosis, 
are  of  no  avail. 

Caries. — Caries  'of  bone  should  no  longer  be  spoken  of  as 
a  disease,  but  as  one  of  the  effects  of  some  destructive  disease  of 
bone.  Macroscopically  and  microscopically  caries  of  bone  re- 
sembles an  ulcer  of  the  soft  parts,  and  it  would  not  be  inappro- 
priate to  describe  it  as  an  ulcer  of  bone.  Tuberculosis  of  the 
periosteum  and  of  bone  are  the  affections  which  most  frequently 
produce  caries.  Every  tubercular  cavity  in  bone  lined  with 
granulations  presents  a  carious  surface  as  long  as  the  primary 
disease  remains  in  an  active  state.  Every  tubercular  abscess  in 
communication  with  a  tubercular  osteomyelitic  focus  has  carious 
bone  at  its  bottom.  A  tubercular  periostitis  leads  to  caries  at  an 
early  stage  by  the  extension  of  the  tubercular  process  to  the  sub- 
jacent bone.  Caries  of  the  articular  extremities  of  the  long  bones 
arises  in  the  course  of  primary  or  secondary  tuberculosis  of  joints 
as  soon  as  the  articular  cartilages,  in  whole  or  in  part,  are  de- 
stroyed by  the  tubercular  granulations.  Caries  of  the  vertebrae, 
like  that  of  other  short,  flat,  and  irregular  bones  so  frequently 
referred  to  in  the  old  text-books,  and  even  in  many  of  more 


88  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS- 

recent  date,  as  a  disease,  is,  in  a  great  majority  of  cases,  nothing 
more  or  less  than  tuberculosis  of  those  bones. 

Destruction  of  articular  cartilage  by  primary  or  secondary 
synovial  tuberculosis  does  not  always  necessarily  result  in  caries 
of  the  articular  ends,  as,  under  favorable  conditions,  the  de- 
structive process  is  arrested  before  it  extends  to  the  bone,  and  a 
new  covering  of  fibrous  tissue  takes  the  place  of  the  articular 
cartilage.  Carious  bone  is  always  covered  more  or  less  by 
granulations,  and  the  enlarged  cancellous  spaces  are  occupied 
by  the  same  material.  The  granulations  detach  small  frag- 
ments of  bone,  which  remain  imbedded  in  the  soft,  flabby  granu- 
lations, and  afterward  become  part  of  the  abscess  contents,  or 
are  eliminated  with  the  discharges  through  fistulous  tracts.  At 
a  little  distance  from  the  tubercular  granulations  the  bone  is 
osteoporotic,  but  immediately  beneath  it  the  cancelli  contain 
young  fibrous  tissue,  and  it  is  here  that  thickening  of  the  tra- 
beculae  takes  place.  After  the  cartilage  has  disappeared  the 
disease  extends  to  the  surface  of  the  bone,  which  soon  becomes 
covered  with  granulations,  in  which  all  of  the  histological 
elements  of  tubercle  can  be  found.  The  tubercular  process 
extends,  step  by  step,  into  the  bone,  new  areas  becoming  suc- 
cessively involved,  while  the  older  portions  undergo  cassation 
and  liquefaction.  Immediately  beneath  the  infected  tissues 
there  is  usually  a  narrow  zone  of  plastic  osteomyelitis,  while 
more  remote  from  the  disease  there  may  or  may  not  be  an 
osteoporotic  condition  of  the  bone,  often  in  circumscribed 
patches.  The  destructive  process  takes  place  most  rapidly  at 
points  subjected  to  greatest  pressure.  Thus,  in  coxitis,  the  rim 
of  the  acetabulum  or  upper  segment  of  the  head  of  the  femur 
suffers  the  most  from  pressure  of  the  head  of  the  femur,  and  in 
tuberculosis  of  the  knee-joint  the  articular  ends  show  the  great- 
est defects  at  points  subjected  to  the  greatest  pressure.  The 
detachment  of  fragments  occurs  by  lacunar  absorption  of  por- 
tions of  the  trabeculae.  This  interstitial  absorption  of  bone  is 
accomplished  exclusively  by  living  granulations,  and  can  only 


BONE   TUBERCULOSIS.  89 

occur  in  places  where  these  have  not  undergone  caseation. 
Surface  caries,  as  a  rule,  is  always  superficial,  never  involving 
more  of  the  bone  than  a  quarter  of  an  inch  in  thickness* 

Caries  sicca  is  a  .form  of  caries  which  was  first  minutely 
described  by  Volkmann  as  a  definite  pathological  variety  of 
tubercular  joint  disease.  The  most  characteristic  features  of 
this  kind  of  caries  are  absence  of  suppuration,  obliteration  of 
the  cavity  of  the  joint,  and  sclerosis  and  concentric  atrophy 
of  the  articular  extremity  of  tJie  bone.  The  yellow  appearance 
of  the  sclerosed  bone  is  due  to  fatty  degeneration  of  the  con- 
tents of  the  cancelli,  and  not  to  infiltration  with  tubercular 
material.  Caries  sicca  is  met  with  most  frequently  in  the 
shoulder-joint,  and  is  a  form  of  joint  tuberculosis  which  most 
frequently  terminates  in  a  spontaneous  cure,  without  surgical 
interference. 

Tubercular  Periostitis. — Tubercular  periostitis  of  the  long 
bones  is  a  comparatively  rare  affection,  being  far  less  frequent 
than  syphilitic  periostitis.  This  affection  as  a  primary  disease 
involves  most  frequently  the  vertebra?,  ribs,  cranium,  and  bones 
of  the  face.  In  the  last  locality  it  attacks  the  orbital  border  of 
the  malar  bone  most  frequently.  As  a  secondary  affection  in 
tuberculosis  of  the  long  bones,  it  develops  most  frequently  in 
connection  with  the  diffuse  infiltrating  form  of  osteotuberculosis. 
In  tuberculosis  of  the  ribs  the  disease  starts  most  frequently  in 
the  periosteum,  and  the  bone  is  gradually  destroyed  from  with- 
out inward.  The  compact  layer  of  the  ribs  at  points  cor- 
responding to  the  disease  in  the  periosteum  shows,  at  first, 
minute  circumscribed  defects,  which  gradually  enlarge,  impart- 
ing to  the  bone  a  worm-eaten  appearance.  The  disease  often 
destroys  the  continuity  of  the  bone,  giving  rise  to  a  patho- 
logical fracture.  It  not  only  spreads  in  the  direction  of  the 
bone,  but  also,  by  continuity,  along  the  periosteum,  terminating 
frequently  only  with  the  destruction  of  the  entire  periosteal 
envelope.  The  periosteum  being  the  primary  starting-point  of 
the  disease,  extension  of  the  process  to  the  tissues  outside  of 


90  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

the  periosteum  is  an  early  occurrence.  In  the  adult,  tuber- 
cular spondylitis  is  most  commonly  the  result  of  an  extension 
of  the  disease  from  the  periosteum.  A  number  of  vertebrae  are 
attacked  simultaneously,  or  in  rapid  sucpession,  and  the  forma- 
tion of  a  tubercular  abscess  must  be  expected.  Curvature  of 
the  spine  is  frequently  absent,  and  when  present  it  is  not  as 
angular  as  when  the  disease  attacks  primarily  the  body  of  one 
or  more  of  the  bones.  As  a  secondary  disease  in  tuberculosis 
of  the  long  bones  it  is  rare,  except  in  the  diffuse  variety. 
When  the  dry,  granulating  focus  reaches  the  periosteum,  a 
small,  soft,  elastic,  limited  granulation  swelling  forms,  first 
under,  later  outside  of  it.  It  is  characterized  by  slow  growth, 
comparatively  little  pain,  slight  tenderness,  and  a  tendency  to 
remain  stationary  for  a  long  time.  If,  however,  the  central 
focus  has  become  cheesy,  and  the  liquefied,  cheesy  material 
comes  in  contact  with  the  periosteum  and  paraperiosteal 
tissues,  a  tubercular  abscess  forms  in  a  short  time.  As  soon  as 
the  periosteum  has  been  perforated  the  cheesy  material  infects 
the  connective  tissue,  which  then  takes  an  active  part  in  the 
formation  of  the  tubercular  abscess ;  the  periosteum  ruptures 
spontaneously,  the  skin  overlying  it  becomes  tubercular  and 
presents  subsequently,  at  the  point  of  perforation,  the  appear- 
ance of  lupus.  In  the  differential  diagnosis  between  a  tuber- 
cular and  syphilitic  periostitis,  the  character  of  the  swelling  is 
of  great  importance.  In  the  former,  central  softening  is  of 
frequent  occurrence,  and  takes  place  earlier  than  in  the  latter ; 
at  the  same  time,  pain  and  tenderness  are  not  as  well  marked  as 
in  syphilitic  gumma  of  the  periosteum. 


CHAPTER  X. 

ETIOLOGY  OF  BONE  TUBERCULOSIS. 

TUBERCULOSIS  of  bone  occurs  either  as  a  primary  or  second- 
ary affection.  In  the  former  instance  we  understand  that  local- 
ization of  the  Bacillus  of  tuberculosis  has  not  taken  place  in  any 
other  organ  of  the  body,  and  that  the  tubercular  lesion  in  bone 
presents  itself  as  an  isolated  single  affection.  Little  is  known 
concerning  the  channels  through  which  primary  infection  takes 
place.  We  have  reason  to  believe  that  this  occurs  most  fre- 
quently through  the  respiratory  and  digestive  organs.  Through 
these  routes  the  bacilli  of  tuberculosis  enter  the  general  circu- 
lation and  localize  in  the  capillary  vessels  of  those  parts  of  the 
bones  which  are  anatomically  predisposed  to  localization  of 
floating  micro-organisms.  The  frequency  with  which  pulmo- 
nary tuberculosis  is  met  with  in  cases  of  bone  tuberculosis,  and 
the  fact  that  the  thoracic  duct  is  also  quite  often  the  seat  of 
tuberculosis,  speak  in  favor  of  this  assumption.  We  have  no 
reliable  evidence  that  infection  rarely,  if  ever,  takes  place 
through  a  wound  in  a  healthy  person.  Clinical  experience 
tends  to  prove  that  primary  tuberculosis  of  bones  and  joints  is 
exceedingly  rare,  or,  perhaps,  does  not  occur  at  all.  The  tuber- 
cular lesions  which  give  rise  to  metastatic  tuberculosis  may  be 
very  minute  and  elude  detection,  even  on  making  a  careful 
examination.  A  small  cheesy  deposit  in  the  lungs,  a  hidden 
caseous  lymphatic  gland,  may  be  sufficient,  under  certain  con- 
ditions, to  give  rise  to  numerous  metastatic  foci.  Carefully- 
made  autopsies  can  only  furnish  additional  reliable  information 
on  this  subject.  Buhl's  assertion,  that  in  tubercular  affections 
of  different  organs  without  an  old  tubercular  focus,  this  was  not 
absent  but  overlooked,  may  yet  receive  corroboration  by  careful 
research  in  the  future.  Orth  made  67  autopsies  in  the  Gottin- 
gen  clinic  of  patients  that  were  the  subjects  of  tuberculosis  of 
bones  and  joints  which  had  been  subjected  to  operative  treat- 

(91) 


92  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

ment.  In  14  of  these,  caseous  foci  were  found  in  other  organs 
which  could  be  regarded  as  the  cause  of  the  bone  and  joint 
affections,  thus  giving  in  only  21  per  cent,  caseous  foci  as  the 
source  for  the  metastatic  bone  and  joint  affections.  The  num- 
ber of  those  in  which  the  post-mortem  revealed  only  osseous 
foci  were  the  following : — 

Of  30  hip-joints,    . 5 

Of  17  knee-joints, 2 

Of    8  ankle-joints, 1 

Of  11  tuberculosis  of  vertebrae, 5 

Of    1  multiple  disease  of  bones, 1 

The  67  autopsies  showed  55  times,  besides  the  bone  and 
joint  disease,  older  foci.  Among  these,  the  lungs  were  the  seat 
37  times;  the  lymphatic  glands  21  times.  Most  frequently  the 
bronchial  glands  were  affected ;  next  in  order  came  the  mesen- 
teric  and  retro-peritoneal,  and  least  frequently  the  glands  of  the 
neck  and  extremities.  The  genito-urinary  organs  were  affected 

9  times,   as   a   rule    complicated   by  pulmonary    tuberculosis. 
Secondary  tuberculosis  of  bones  and  joints  is  a  common  clin- 
ical occurrence.     As  has  been  previously  stated,  what  is  gen- 
erally regarded  as  a  local  bone  tuberculosis  (by  which  we  mean 
the  absence  of  recognizable  tubercular  lesions  in  other  organs) 
is,   in  reality,   in   the   majority  of  cases,  a   secondary   disease, 
resulting  from  the  introduction  of  bacilli  through  the  respira- 
tory or  alimentary  tract  into  the  circulating  blood  with  localiza- 
tion in  the  bone,  or  the  entrance  of  bacilli  into  the  circulation 
from  a  pre-existing  but  undetectable  tubercular  product  with 
secondary  localization  in  bone.     In  this  sense  a  primary,  or,  to 
use  a  more  correct  expression,  a  localized  osseous  or  articular 
tuberculosis  is,  according  to  Kummer,  found  in  about  40  per 
cent,  of  the  cases ;  in  the  remaining  60  per  cent,  depots  are 
found  at  the  same  time  in  other  organs :  the  lung  comes  first, 
with  25  per  cent. ;  then  joints,  10  per  cent. ;  afterward  bones, 

10  per  cent. ;  lymphatic  glands,  10  per  cent. ;  peritoneum,  3 
per  cent. ;  pleura,  2  per  cent. ;   the  usual  history  being  in  such 
cases  something  as  follows :  A  patient  has  passed  through  an 


ETIOLOGY    OF    BONE   TUBERCULOSIS.  93 

attack  of  pleuritis,  during  which  he  has,  perhaps,  expectorated 
blood;  but  after  awhile  apparent  recovery  follows,  but  the 
patient  has  lost  a  great  deal  of  flesh  and  does  not  gain  in 
weight ;  at  the  same  time  the  appetite  is  impaired.  Fre- 
quently, more  or  less  cough  remains ;  a  slight  trauma  lights 
up  an  inflammation  of  a  joint ;  a  tubercular  abscess  forms, 
which  communicates  with  an  osseous  focus.  In  persons 
advanced  in  years,  a  primary  synovial  tuberculosis  is  likely  to 
develop  under  such  circumstances.  At  other  times  an  osseous 
or  joint  tuberculosis  is  preceded  by  a  tubercular  affection  of  the 
genitourinary  organs.  A  correct  diagnosis  in  such  cases  can 
usually  be  made  without  much  difficulty.  In  persons  the  sub- 
jects of  a  cheesy  deposit  in  some  organ  of  the  body  a  metas- 
tatic  affection  of  bones  or  joints  frequently  follows  a  slight  injury. 
In  Konig's  cases  such  a  connection  between  an  old  tuber- 
cular process  and  a  trauma  causing  bone  tuberculosis  was 
always  established.  Even  in  persons  apparently  in  good  health 
the  subsequent  history  revealed  the  existence  of  a  tubercular 
affection  of  long  standing,  and  he  relates  a  number  of  interesting 
cases  which  substantiate  this  statement.  After  a  trauma,  how- 
ever, the  tubercular  lesion  can  originate  in  the  same  manner  as 
in  acute  osteomyelitis,  in  which  a  depot  in  the  body  does  not 
invariably  exist.  In  such  cases  we  must  take  it  for  granted 
that  the  bacilli  which  have  entered  the  circulation  through  the 
respiratory  or  digestive  organs  have  not  localized  until  the  locus 
minoris  resistentice  is  created  by  the.  trauma.  The  trauma  only 
serves  as  an  exciting  cause  in  the  production  of  bone  tuberculosis 
in  persons  already  infected  with  the  essential  cause.  Clinically, 
tuberculosis  of  the  bones  can  be  traced  only  in  a  small  percentage 
of  the  cases  to  a  traumatic  origin.  It  is,  as  Volkmann  asserted 
long  ago,  characteristic  that  the,  traumatism  is  always  slight, 
often  quite  insignificant;  tuberculosis  of  bone,  even  in  tubercular 
subjects,  seldom,  if  ever,  follows  a  fracture,  as  the  injury  in 
such  cases  is  productive  of  such  active  cell-proliferation  that  it 
will  hold  in  abeyance  the  pathogenic  action  of  the  bacilli  which 


94  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

might  reach  the  seat  of  injury  with  the  extravasated  blood.  It 
is  also  possible  that,  in  many  cases  at  least,  the  attention  of  the 
patient  or  his  friends  is  first  accidentally  called  to  an  existing 
tubercular  focus  by  the  immediate  effects  of  the  injury,  the 
latter  having  had  no  influence  in  the  causation  of  the  disease. 
Every  child  large  enough  to  run  around  injures  himself  more  or 
less  almost  daily,  and  yet  tuberculosis  of  bones  and  joints  follows 
as  a  consequence  only  in  comparatively  few;  and  in  such 
cases  the  essential  cause  must  be  present  in  the  blood  or  tissues 
at  the  time  the  injury  is  received.  To  show  the  influence  of 
trauma  in  exciting  tubercular  disease  of  bone,  Cheyne  (British 
Medical  Journal,  April  25,  1891)  made  a  study  of  293  cases 
which  came  under  Sir  Joseph  Lister's  and  his  own  observation 
during  the  course  of  several  years.  In  188  of  these  cases  no 
definite  cause  was  assigned,  while  in  105,  or  38.8  per  cent,  of 
the  whole,  the  trouble  was  directly  ascribed  to  the  injury.  In 
these  cases  the  males  were  considerably  in  excess  of  the  females, 
namely,  194  :  99,  or  66  per  cent. :  34  per  cent.  Of  the  194 
males  there  was  no  history  of  injury  in  113,  and  of  the  99 
females  there  was  none  in  75,  or  a  percentage  proportion  of 
uninjured  males  and  females  of  66  :  40.  This  leaves  81  males 
and  24  females  with  a  history  of  injury,  or  a  percentage  propor- 
tion of  77  :  23.  The  facts  are  more  striking  if  we  contrast  the 
cases  commencing  before  and  after  10  years  of  age,  in  males 
and  females  respectively,  as  shown  in  the  following  table : — 


Percentage  Proportion  of  ' 

First  Decade. 

Later. 

Uninjured  and  injured  males,  . 

.     67.1:32.9 

53.2:46.8 

Uninjured  and  injured  females, 

.     68.8:31.2 

81.5:18.5 

Total  males  to  total  females, 

.     60.8:39.2 

69.6:30.4 

Uninjured  males  and  uninjured  females, 

.     60.2:39.8 

60.0  :  40.0 

Injured  males  to  injured  females, 

.     62.1  :  37.9 

85.3:14.7 

Uninjured  males  during  the  two  periods,  . 

«         .         .         . 

41.6:584 

Uninjured  females  during  the  two  periods, 

•        «        • 

40.3:59.7 

Injured  males,      

.         . 

28.4  :  71.6 

Injured  females, 58.4:41.6 

Before  10  years  of  age  the  liability  in  males  and  females 
is  about  the  same,  showing  that  the  injuries  to  which  males  are 


ETIOLOGY    OF   BONE   TUBERCULOSIS. 


95 


more  subjected  alter  this  time  of  life  play  an  important  part  in 
the  causation  of  tubercular  affections  of  bone  and  joints,  as 
after  60  years  of  age  the  proportion  in  both  sexes  is  again  about 
the  same.  The  cases  following  an  injury,  as  a  rule,  are  of  a 
graver  form. 

Thus,  of  301  cases  of  tubercular  disease  of  joints  collected 
by  Cheyne,  the  bone  was  primarily  affected  in  94,  or  31.2  per 
cent. ;  of  193  uninjured  cases,  the  bone  was  the  primary  seat 
of  the  disease  in  41,  or  37.9  per  cent.  Chronic  inflammation  is 
a  local  predisposing  cause  to  tubercular  inflammation.  Suppu- 
ration aids  in  spreading  the  disease,  which  is  best  shown  by  the 
difference  in  the  behavior  of  tubercular  joints  incised  with  and 
without  antiseptic  precautions.  Tubercular  meningitis  more 
frequently  develops  in  connection  with  septic  than  aseptic  tuber- 
cular lesions.  In  reference  to  age  as  a  predisposing  factor, 
Cheyne  gives  the  following  table : — 


1-5 

6-10 

11-15 

16-20 

21-25 

26-50 

31-35 

36-40 

41-45 

46-50 

Above  50. 

Total  .... 

23.2 

16.0 

14.6 

15.0 

8.5 

8.8 

4.0 

3.0 

2.0 

2.0 

2.0 

Males.    .  .  . 

11.3 

9.5 

9.5 

9.  -5 

6.3 

5.3 

4.0 

2.4 

2.0 

1.8 

1.0 

Females    .  . 

8.8 

6.5 

,0 

5.8 

2.0 

3.3 

0.8 

0.4 

1.0 

It  is  also  interesting  to  note  that  age  predisposes  to  the 
localization^  of  the  tubercular  process  in  certain  joints.  Cheyne 
gives  the  following  table  to  illustrate  that  part  of  the  etiology 
of  tuberculosis  of  bones  and  joints : — 


t,' 

• 

g 

. 

QJ 

3 

B 

•W 

<D 

^ 

• 

3 

XI 

o 

® 

"C 

a 

W 

M 

« 

& 

a 

3 

^ 

a, 

00 

First  decade      

30  2 

295 

54 

4  6 

6.7 

0.6 

12.0 

Second  decade  .... 

20  3 

22  8- 

5  9 

5.9 

1  6 

8.4 

15  2 

Third  decade           .... 

4.8 

182 

3.6 

84 

4.8 

6.0 

15  8 

28.0 

Fourth  decade  

36.6 

3.3 

3.3 

133 

13.3 

20.0 

Fifth  decade  

12.5 

6.2 

12.5 

18.7 

18.7 

6.2 

12.5 

Heredity  is  an  important  factor  in  the  causation  of  bone 
tuberculosis,  as  well  as  tuberculosis  of  other  organs.     Tubercu- 


96  TUBERCULOSIS    OF   THE   BONES    AND   JOINTS. 

losis  in  the  newborn  has  never  been  found  in  this  locality,  but 
it  is  well  known  that  it  can  appear  within  a  few  months  after 
birth,  and  the  conditions  under  which  this  occurs  are  familiar. 
I  have  repeatedly  observed  well-marked  and  typical  tubercular 
lesions  of  bone  and  joints  in  infants  from  a  few  months  to  a 
year  of  age,  in  exciting  tubercular  disease  of  bone.  In  188  of 
the  cases  reported  by  Watson  Cheyne  we  must  take  it  for 
granted  that  direct  transmission  from  parent  to  child  is  possible, 
but  that  it  takes  place  very  rarely.  A  hereditary  predisposition 
to  tuberculosis  exists,  and  has  for  years  been  quite  generally 
accepted  as  a  well-established  clinical  fact.  By  this  is  meant  a 
peculiar  vulnerability  of  the  tissues  and  a  susceptibility  to 
tubercular  infection.  In  children  so  predisposed  the  clinical 
history  often  reveals  obstinate  eczema,  blepharitis  ciliaris,  gland- 
ular enlargements,  and  other  affections  of  undoubted  tubercular 
nature  during  early  childhood,  preceding  the  bone  affection. 
Surgeons  are  well  aware  of  the  fact  that  the  existence  of  a 
hereditary  tendency  to  tuberculosis  adds  greatly  to  the  gravity 
of  the  disease.  The  course  is  usually  more  rapid,  spontaneous 
cure  less  likely,  and  the  prospects  of  a  favorable  result  after 
operative  treatment  less  favorable  than  in  the  acquired  form  of 
bone  tuberculosis.  Wealth  furnishes  no  protection  against  this 
form  of  bone  affection,  as  it  is  equally  prevalent  among  the  rich 
and  the  poor.  The  diseases  incident  to  infancy  and  childhood, 
such  as  pertussis,  rubeola,  and  scarlatina,  frequently  furnish  the 
necessary  conditions  for  the  development  of  osteotuberculosis. 
In  the  adult  the  attack  is  often  preceded  by  one  of  the  acute 
infectious  diseases,  such  as  typhoid  fever,  pneumonia,  and 
pleuritis.  Pregnancy  and  lactation  are  also  important  etio- 
logical  factors. 


CHAPTER  XL 

SYMPTOMS  AND  DIAGNOSIS  OF  TUBERCULAR  BONE  AFFECTIONS. 

DURING  the  early  stage  of  tubercular  inflammation  of  bone 
the  first  local  symptoms  are  often  referred  to  the  nearest  joint, 
and  in  osteotuberculosis  of  the  hip  to  the  knee-joint.  The 
general  symptoms  are  often  no  indication  of  the  existence  or 
extent  of  the  local  disease,  as  patients  with  quite  extensive  bone 
tuberculosis  may  present  every  appearance  of  perfect  health,  and 
a  small  osseous  focus  may  produce  a  rapidly  fatal  miliary  tuber- 
culosis. Uncomplicated  tuberculosis  of  bone  is  essentially  a 
chronic  process,  and  the  general  symptoms  furnish  but  little 
information  in  reference  to  its  inflammatory  character.  Febrile 
reaction  is  slight  or  entirely  absent.  More  than  ten  years  ago, 
Konig  called  attention  to  the  fact  that  a  slight  rise  in  the  tem- 
perature is  frequently  present,  even  in  limited  local  tuberculosis. 
If  the  thermometer  shows  a  normal  or  subnormal  morning 
temperature,  and  a  slight  rise  toward  evening,  if  not  more  than 
half  a  degree  Fahrenheit,  but  continued  for  weeks  and  months, 
it  indicates  a  careful  search  for  a  local  tubercular  focus.  The 
local  surface  temperature  is  not  sensibly  increased.  Progressive 
anaemia  is  always  an  unfavorable  symptom  in  all  forms  of  local 
tuberculosis,  as  it  indicates  either  the  presence  of  additional  foci 
in  important  organs,  or  accompanies  the  exhaustive  purulent 
discharges  after  secondary  infection  with  pus-microbes. 

Laker  ("  Die  Bestimmung  des  Haemoglobingehaltes  im 
ISlute  mittels  des  von  Fleischl'  schen  Hsemometers."  Wiener 
Med.  Woclienschrift,  B.  xxxvi,  1886)  has  ascertained  that  the 
blood  of  patients  suffering  from  bone  and  joint  tuberculosis  is 
deficient  in  haemoglobin.  The  occurrence  of  mixed  infection, 
with  or  without  a  direct  infection-atrium,  is  usually  announced 
by  a  high  temperature  and  other  symptoms  of  septic  infection. 
Emaciation  is  seldom  a  marked  feature  of  bone  tuberculosis 
unless  a  number  of  bones  are  affected  simultaneously,  or  after 

7  (97) 


98  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

the  case  has  resulted  in  the  formation  of  tubercular  abscesses 
which  have  become  the  seat  of  secondary  infection  with  pus- 
microbes. 

The  local  symptoms  vary  according  to  the  location,  condi- 
tions, and  size  of  the  tubercular  focus  and  the  presence  or 
absence  of  complications. 

Pain. — Pain  is  an  almost  constant  symptom,  but  its  in- 
tensity is  subject  to  great  variation.  Unlike  in  acute  suppurative 
inflammation  of  bone,  the  inflammatory  product  does  not  give 
rise  to  the  same  degree  of  tension ;  hence,  pain  is  not  so  promi- 
nent a  symptom.  The  primary  exudation  and  transudation  in 
tubercular  inflammation  are  always  scanty,  and  the  inflamma- 
tory product  is  composed  mostly  of  granulation  tissue  derived 
from  pre-existing  fixed  tissue-cells ;  at  the  same  time  the  sur- 
rounding bone-tissue  becomes  osteoporotic,  and  yields  more 
readily  to  pressure.  Consequently,  tension  is  to  a  great  extent 
avoided,  and  pain  is  slight  as  compared  with  the  acute  and 
intense  suffering  caused  by  acute  osteomyelitis.  Children  suffer- 
ing from  spina  ventosa  complain  of  little  or  no  pain,  although  a 
whole  phalanx  of  a  finger  may  be  almost  completely  destroyed 
by  a  tubercular  osteomyelitis.  In  such  cases  the  granulation 
tissue  is  formed  slowly;  the  compact  layer  of  the  bone  is 
rendered  osteoporotic  and  becomes  greatly  attenuated,  and  gen- 
erally yields  readily  to  the  prolonged  intra-osseous  pressure  and 
expands,  perhaps,  to  twice  its  normal  circumference.  Pain  is 
slight,  or  entirely  absent,  because  no  great  intra-osseous  tension 
has  occurred.  That  tension  or  pressure  greatly  aggravates  pain 
fn  osseous  tuberculosis  is  one  of  the  most  familiar  facts  in 
surgery.  This  symptom  is  promptly  relieved  in  a  case  of  tuber- 
cular spondylitis  by  suspension  and  fixation  and  rest  in  the 
recumbent  position,  and  greatly  aggravated  by  flexion  of  the 
spinal  column,  which  necessarily  produces  pressure  upon  the 
bodies  of  the  inflamed  vertebrae.  In  osteo-arthritis  of  the  large 
joints  pain  is  relieved  by  rest  and  extension,  and  is  always 
increased  by  use  of  the  limb  or  by  pressing  the  inflamed  articular 


SYMPTOMS  AND    DIAGNOSIS    OF   TUBERCULAR    BONE    AFFECTIONS.       99 

surfaces  against  each  other.  It  may  be  stated,  as  a  rule,  that 
the  intensity  of  the  pain  bears  a  direct  relationship  to  the  acute- 
ness  of  the  inflammatory  process.  The  pain  is  of  a  dull,  aching 
character,  and  is  intermittent  and  more  severe  during  the  night. 
The  nocturnal  exacerbation  of  the  pain,  as  evidenced  in  children 
by  restlessness  during  sleep,  moaning,  grinding  of  teeth,  and 
horrible  dreams,  is  often  one  of  the  first  symptoms  which  excites 
suspicion  of  the  existence  of  osteotuberculosis.  The  pain  is  not 
always  referred  to  the  seat  of  lesion.  Tubercular  osteomyelitis 
of  the  head  and  neck  of  the  femur  gives  rise  to  pain  in  the 
region  of  the  knee-joint,  which  is  intensified  by  movements  of 
the  hip-joint  or  by  making  pressure  against  the  great  trochanter, 
while  manipulation  of  the  knee-joint,  if  the  hip  is  immobilized, 
does  not  increase  it.  Children  suffering  from  tuberculosis  of 
the  spine  usually  refer  all  the  suffering  to  the  pit  of  the  stomach, 
or  to  some  other  part  of  the  abdomen  supplied  with  nerves  that 
take  their  exit  from  the  spinal  canal  at  a  point  corresponding 
to  the  inflamed  vertebrae. 

Tenderness. — The  periosteum  covering  the  bone  overlying 
an  osseous  focus  at  a  comparatively  early  stage  of  the  disease 
becomes  the  seat  of  inflammation  before  it  is  reached  by  the 
tubercular  process.  This  circumscribed  periostitis  gives  rise  to 
tenderness.  The  existence  of  cm  area  of  tenderness  over  a 
point  corresponding  to  a  tubercular  focus  in  tfie  interior  of  a 
bone  is  one  of  the  surest  indications  of  the  existence  of  osteo- 
tuberculosis. In  many  cases  of  epiphysial  tuberculosis  patients 
have  been  treated  for  some  supposed  lesion  in  the  adjacent 
joint,  simply  because  this  symptom  was  not  carefully  searched 
for,  or,  if  discovered,  its  significance  was  misinterpreted.  In 
such  cases  the  existence  of  a  limited  area  of  tenderness  in  the 
epiphysial  line  and  the  absence  of  joint-lesions  will  enable  the 
surgeon  to  locate  accurately  a  focus  in  the  interior  of  the  bone. 
The  area  of  tenderness  to  be  outlined  by  making  pressure  at 
different  points  with  the  tip  of  the  index-finger  at  least  approxi- 
mately corresponds  with  the  circumference  of  the  tubercular 


100  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

focus.  If  more  than  one  focus  is  present  in  the  articular 
extremity  of  a  long  bone  the  number  of  tender  points  will  cor- 
respond with  the  number  of  foci  in  the  bone.  Whether  a  cen- 
tral focus  in  a  bone  could  be  always  recognized  by  relying  upon 
this  symptom  is  somewhat  doubtful;  but  usually  the  foci  are 
located  sufficiently  near  the  surface  of  the  bone  to  give  rise  to 
secondary  limited  periostitis  and  points  of  tenderness,  which  can 
be  readily  located  by  ringer  pressure.  In  the  examination  of 
tubercular  joints  it  is  important  to  search  for  this  symptom  over 
both  articular  extremities,  for  the  purpose  of  detecting  osseous 
foci, — a  matter  of  great  importance  not  only  from  a  diagnostic, 
but  also  from  a  therapeutic,  stand-point. 

Swelling. — The  opinion  prevailed  among  surgeons  for  a 
long  time  that  the  swelling  in  tumor  albus  was  caused  by 
enlargement  of  the  articular  extremities  of  the  bones.  Mr. 
Lawrence,  of  St.  Bartholomew's  Hospital,  first  called  the  atten- 
tion of  Mr.  Crowther  ("•  Crowther  on  AVliite  Swelling."  Lon- 
don, 1808)  to  the  fact  that  in  the  specimens  of  white  swellings 
in  the  museum  in  that  institution  the  diseased  bones  did  not 
show  any  enlargement.  Until  that  time  it  had  always  been 
taught  that  in  this  disease  the  bones  underwent  enlargement ; 
but  the  specimens  examined  for  this  special  purpose  demon- 
strated the  incorrectness  of  this  assertion.  Samuel  Cooper 
("  First  Lines  of  the  Practice  of  Surgery,  and  a  Concise  Book 
of  Reference  to  Practitioners  "),  somewhat  later,  made  the  fol- 
lowing statement  concerning  this  question :  "  I  have  been  in 
the  habit  of  frequently  inspecting  the  state  of  the  numerous 
diseased  joints  which  are  annually  amputated  in  St.  Bartholo- 
mew's Hospital ;  and,  though  I  have  long  been  attentive  to  this 
point,  my  searches  after  a  really  enlarged  scrofulous  bone  have 
always  been  in  vain."  Mr.  Crowther  very  properly  remarks 
that  an  exception  should  be  made  in  the  case  of  spina  ventosa, 
an  affection  in  every  way  analogous  to  strumous  disease  of  the 
articular  ends  of  the  long  bones,  and  in  which  the  spindle- 
shaped  enlargement  of  the  bone  is  the  most  characteristic  fea- 


Life  op 

COLLEGE  o,    CITEGrATK 

SYMPTOMS  AND  DIAGNOSIS  OF  TUBERCULAR  BONE  AFFECTIONS.       10},  f( 

ture  of  the  disease.  I  have  also  seen  a  number  of  cases  of 
diffuse  tubercular  osteomyelitis  of  the  long  bones  in  which  the 
shaft  was  much  enlarged,  its  surface  irregular,  the  bone  itself 
softened,  and  presenting  numerous  defects.  The  diffuse  form  of 
tubercular  osteomyelitis  is  always  attended  by  a  plastic  osteomy- 
elitis, and,  consequently,  the  early  appearance  of  external  swell- 
ing is  one  of  the  points  to  be  taken  into  consideration  in  differ- 
entiating between  the  different  forms  of  osteotuberculosis. 
With  these  exceptions  the  bone  itself  is  generally  not  much 
enlarged  by  tubercular  inflammation.  External  swelling  is 
absent  until  the  atrophic  layer  of  compact  bone  yields  to  the 
intra-osseous  pressure, — as  may  be  seen  in  advanced  cases  of 
spina  ventosa, — or  until,  by  pressure-atrophy  over  the  centre  of 
the  focus,  the  compact  layer  is  perforated,  and  a  soft,  circum- 
scribed, boggy  swelling  forms  underneath  the  periosteum.  If 
the  granulation  tissue  has  retained  its  vitality  the  extra-osseous 
swelling  increases  very  slowly  in  size,  and  there  is  no  tendency 
to  diffuse  infection  of  the  connective  tissue  after  the  tubercular 
product  has  reached  the  paraperiosteal  tissues.  Pseudo-fluctu- 
ation is  generally  present,  and  many  such  granulating  foci  at 
this  stage  have  been  carelessly  incised  under  the  mistaken  diag- 
nosis of  abscess.  If  the  central  focus  has  undergone  caseation 
before  the  periosteum  is  perforated,  then  the  paraperiosteal 
tissues  become  rapidly  infected,  and  a  tubercular  abscess,  such 
as  has  been  described  above,  develops  in  a  short  time.  The 
abscess  wanders  away  from  the  place  where  it  originated  in 
directions  offering  the  least  resistance,  along  preformed  anatom- 
ical spaces,  and  in  obedience  to  the  law  of  gravitation.  The 
size  of  such  an  abscess  is,  absolutely,  no  indication  of  the 
extent  of  the  primary  lesion  in  the  bone,  as  a  minute  focus  may 
be  the  cause  of  a  large  abscess,  and  a  small  abscess  may  mark 
the  location  of  an  extensive  primary  bone-lesion.  (Edema  is 
usually  not  well  marked,  even  if  the  abscess  is  large,  unless 
secondary  infection  with  pyogenic  microbes  has  occurred.  The 
swelling  that  attends  tuberculosis  in  bones  deeply  seated — as 


nl  SIJ 

•MHYftieBYiro  ^o  ^ii 


TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

the  vertebra?,  head  and  neck  of  femur,  and  pelvic  bones — does 
not  become  apparent  until  the  existence  of  a  tubercular  abscess 
indicates  the  probable  seat  of  the  primary  lesion. 

Redness. — The  skin  over  a  tubercular  focus,  in  the  interior 
of  a  bone  or  over  a  tubercular  abscess,  presents  a  normal  ap- 
pearance until  it  has  become  infected  and  shows  other  unmis- 
takable signs  of  tuberculosis.  Before  this  has  occurred  the  skin 
stretched  over  a  deep-seated  tubercular  product  is  thinner  than 
normal,  extremely  pale,  and  usually  traversed  by  large  and  con- 
spicuous veins,  and  not  attached  to  the  deep  tissues.  More 
serious  changes  in  the  skin  do  not  occur  until  the  granulations 
have  permeated  its  deeper  layers,  or  until  the  caseous  material 
has  become  subcutaneous.  Under  such  circumstances  the  skin 
presents  a  dusky-red  or  livid,  leaden  hue,  owing  to  impaired 
capillary  circulation,  and  becomes  more  and  more  attenuated  by 
pressure-atrophy  and  destructive  changes,  until  it  finally  yields 
to  the  pressure  from  beneath,  and  spontaneous  evacuation  of 
the  contents  of  the  abscess  takes  place.  If  the  subcutaneous 
product  is  composed  of  granulation  tissue,  the  undermined  skin, 
after  perforation  has  taken  place,  is  destroyed  by  degrees,  and 
the  parts  present  the  appearance  of  lupus. 

Atrophy  of  Limb. — Atrophy  of  bone  and  muscles  is  a  con- 
stant symptom  in  osteotuberculosis  as  well  as  in  tubercular 
synovitis.  This  atrophy  is  not  caused  altogether  by  inactivity 
of  the  limb,  but  appears  to  be  due,  in  part  at  least,  to  tropho- 
neurotic  lesions.  In  an  exhaustive  paper  on  this  subject, 
Duplay  and  Cazin  (Archives  Generates  de  Medecine^  January, 
1891)  first  review  the  various  theories  which  have  been  advanced 
at  different  times  to  explain  the  secondary  muscular  atrophy  in 
connection  with  tuberculosis  of  bone  and  joints,  such  as  me- 
chanical stretching,  functional  inactivity,  propagation  of  inflam- 
mation to  the  muscles,  and  vasomotor  changes,  all  of  which 
appear  to  them  insufficient.  Most  authors  have  accepted  the 
reflex  theory,  advanced  first  by  Vulpian,  namely,  that  the  irrita- 
tion of  the  ends  of  the  articular  nerves  reflect  back  on  the  spinal 


SYMPTOMS  AND   DIAGNOSIS  OF  TUBERCULAR  BONE  AFFECTIONS.       103 

centres,  and  from  there  upon  the  centres  of  origin  of  the  muscu- 
lar nerves.  This  accounts  well  for  the  rapid  development  of 
the  atrophy,  the  absence  of  the  reaction  of  degeneration,  and 
the  simple  atrophy  found  in  the  muscles.  In  one  case  Klippel 
found  degenerative  atrophy  in  the  muscles  and  changes  in  the 
corresponding  anterior  horn,  but  this  is  altogether  exceptional. 
One  may  believe  with  Charcot  that  there  are  two  kinds  of  this 
muscular  atrophy, — one  functional,  with  simple  atrophy;  the 
other  more  serious,  with  organic  lesions  in  the  cord  and  degen- 
erative atrophy  of  the  muscles.  Duplay  and  Cazin  studied  this 
subject  experimentally  on  dogs  and  rabbits.  They  produced 
artificially  inflammation  of  joints  by  injecting  nitrate  of  silver  or 
tincture  of  iodine,  or  by  the  use  of  the  actual  cautery.  The 
muscles  weighed  always  showed  a  loss, — in  one  or  two  instances 
as  much  as  40  per  cent.,  usually  in  proportion  to  the  duration 
of  life  (four  to  fifty-one  days).  In  one  experiment  the  joint  was 
mechanically  injured,  and  the  animal  was  allowed  to  live  for  a 
year.  Histological  examination  showed  a  simple  atrophy  in  the 
muscles,  and  the  nerves  were  all  healthy  except  the  articular 
branches.  Here  there  was  a  diminished  number  of  nerve-fibres, 
a  few  of  which  were  degenerated,  the  axis-cylinder  having  dis- 
appeared. The  nerve-sheath  showed  inflammatory  changes,  but 
the  endoneurium  was  unaffected.  This  agrees  perfectly  with 
the  theory  of  Vulpian.  The  predominance  of  the  change  in  the 
extensor  muscles  may  be  explained  by  the  relation  of  the  articu- 
lar nerves  to  the  nerves  supplying  these  muscles.  This  cannot 
take  place  without  the  intervention  of  the  spinal  cord,  and,  in- 
deed, a  connection  between  the  centres  of  the  articular  and 
muscular  nerves  in  the  cord  may  be  assumed.  Struempell 
("Ueber  Muskelatrophie  bei  Gelenk-leiden  und  iiber  Atroph- 
ische  Muskel-lahmung  nach  Ablauf  des  acuten  Gelenkrheuma- 
tismus."  MiincJi.  Med.  Wocliensclirift,  No.  13,  1888)  is  of  the 
opinion  that  muscular  atrophy,  which  attends  inflammatory 
affections  of  joints,  follows  in  consequence  of  the  extension  of  the 
pathological  conditions  directly  from  the  joint  to  the  muscles. 


104  TUBERCULOSIS  OF   THE    BONES   AND   JOINTS. 

Bock  ("Contribution  a  1'etude  de  1'arthrite  mono-articu- 
laire  chronique  et  son  traitement."  Journ.  de  Bruxelles,  June 
20,  1888)  believes  that  in  disease  of  the  knee-joint  the  triceps 
femoris  undergoes  serious  nutritive  changes  in  consequence  of 
an  ascending  neuritis  of  the  nerve  which  supplies  this  muscle, 
and  explains  the  immunity  of  the  sciatic  by  calling  attention  to 
the  intimate  relation  of  the  former  nerve  to  the  joint  and 
periosteum,  which  make  it  possible  for  the  inflammatory  process 
to  extend  from  the  joint  directly  to  the  nerve,  while  the  sciatic 
has  no  such  direct  anatomical  connection  with  the  joint.  The 
same  explanation  is  given  by  Garrod  ("A  Contribution  to  the 
Theory  of  the  Nervous  Origin  of  Rheumatoid  Arthritis."  Med. 
Cldr:  Transactions,  vol.  Ixxi,  p.  89)  of  the  occurrence  of  muscular 
atrophy  in  cases  of  arthritis  deformans.  The  following  conclu- 
sions may  be  drawn:  1.  The  usual  inactive  atrophy  of  the 
affected  limb  in  bone  and  joint  tuberculosis  is  a  simple  atrophy, 
and  in  the  majority  of  cases  is  increased  by  a  simple  reflex,  set 
up  by  the  irritation  of  the  terminal  filaments  of  the  articular 
nerves.  The  pathology  clearly  pointed  out  by  Yulpian  has  thus 
minutely  been  demonstrated  by  the  facts  of  morbid  anatomy. 
2.  In  exceptional  cases  muscular  atrophy  is  caused  by  extension 
of  the  inflammation  from  a  bone  or  joint  to  terminal  nerves 
supplying  the  muscles,  or  to  the  muscles  directly.  The  atrophy 
of  the  limb  is  not  limited  to  the  muscles,  but  later  nearly  all  of 
the  tissues  are  concerned  in  the  process.  In  advanced  cases 
this  atrophy  proves  obstinate  to  treatment,  even  after  the  bone- 
or  joint-  lesion  has  been  completely  cured,  and  on  account  of 
this  the  functional  results  are  so  seldom  perfect. 

Differential  Diagnosis. — With  few  exceptions,  a  chronic 
inflammation  in  the  epiphysial  extremities  of  the  long  bones  or 
in  the  body  of  a  vertebra  is  of  a  tubercular  character.  In  95 
out  of  every  100  cases,  chronic  inflammation  in  bone  means 
tuberculosis,  and,  unless  there  are  special  reasons  which  should 
render  the  diagnosis  doubtful,  it  is  safe  to  adopt  a  treatment 
adapted  for  tubercular  osteomyelitis  in  almost  every  case  where 


SYMPTOMS  AND  DIAGNOSIS  OF    TUBERCULAR   BONE  AFFECTIONS.       105 

the  symptoms  point  to  a  chronic  inflammation,  and  the  existence 
of  syphilis  and  a  tumor  or  parasitic  growth  can  be  excluded. 
In  doubtful  cases  certain  diagnostic  measures  should  be  resorted 
to,  in  order  to  enable  the  surgeon  to  make  a  positive  differ- 
ential diagnosis.  One  of  these  diagnostic  resources  is 

Alc'ulo-peurastik. — Exploration  of  a  doubtful  swelling  with 
a  stout  steel  needle  was  introduced  by  Middeldorpf,  for  the 
purpose  of  ascertaining  the  consistence  and  probable  structure 
of  the  tissue  composing  the  swelling.  He  called  this  simple 
and  often  valuable  diagnostic  aid  altido-peurastik.  The  pres- 
ence of  a  tubercular  focus  in  the  interior  of  a  bone  can  often 
be  demonstrated  by  this  harmless  diagnostic  resource  before 
any  external  swelling  has  appeared.  In  place  of  a  solid  steel 
needle,  a  long  and  strong  needle  of  an  exploring-syringe  can 
be  used  for  puncturing  a  bone  the  density  of  which  has  been 
diminished  by  chronic  inflammation,  if  this  latter  has  not  been 
succeeded  by  osteosclerosis.  During  the  active  stage  of  osteo- 
tuberculosis  the  bone,  for  a  considerable  distance  around  the 
focus,  is  osteoporotic,  and  can  be  readily  penetrated  by  a  strong, 
sharp,  hollow  needle.  The  exploration  should  always  be  made 
under  strict  antiseptic  precautions,  which  always  include  thor- 
ough disinfection  of  the  needle  and  of  the  surface  where  the 
puncture  is  to  be  made.  The  puncture  is  made  in  the  centre 
of  the  tender  area,  and  in  a  direction  corresponding  to  the 
probable  location  of  the  central  focus.  If  the  needle  meet 
with  any  considerable  resistance  in  the  bone  it  is  advanced  by 
rotatory  movements  ;  the  arrival  of  the  point  in  the  granulating 
centre  or  caseous  focus  is  announced  by  a  sudden  loss  of  resist- 
ance. By  advancing  the  needle  sufficiently  to  touch  with  the 
point  the  opposite  side  of  the  cavity  its  probable  size  and  exact 
location  can  be  ascertained.  In  tubercular  necrosis,  if  the 
sequestrum  is  hard,  the  needle  meets  with  greater  resistance 
as  soon  as  it  has  entered  the  cavity  and  has  come  in  contact 
with  the  dead  bone. 

Inoculation  Experiments. — If  the  needle  of  an  exploring 


106  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

or  hypodermatic  syringe  is  used  to  make  the  akido-peurastik,  the 
exploration  of  the  bone  may  be  followed  by  removing  some  of 
the  contents  of  the  cavity  by  aspiration  for  examination.  If 
the  tubercular  product  has  undergone  caseation  and  liquefac- 
tion some  of  the  cheesy  material  can  be  removed  by  aspiration, 
and  the  nature  of  the  lesion  may  then  be  revealed  by  positive 
demonstration  of  the  presence  of  the  bacillus  of  tuberculosis. 
If  still  further  evidence  is  required  a  guinea-pig  can  be  inocu- 
lated with  the  same  needle,  which  still  contains  enough  of  the 
material  to  produce  a  positive  result  in  the  animal.  If  the  cavity 
contain  granulation  tissue,  little  fragments  of  this  can  be  drawn 
into  the  needle,  and  with  these  inoculation  experiments  for 
diagnostic  purposes  can  be  made.  If  a  tubercular  abscess  has 
formed,  the  character  of  the  contents  of  the  swelling  can  be 
determined  by  rising  the  exploring-syringe,  and  the  nature  of 
the  primary  cause  demonstrated,  if  need  be,  by  injecting  the 
material  aspirated  into  the  subcutaneous  tissue  or  peritoneal 
cavity  of  a  guinea-pig. 

Probing. — Examination  of  fistulous  tracts  with  a  probe  for 
diagnostic  purposes  has  been,  and  still  is,  a  much-abused  prac- 
tice. I  must  enter  an  earnest  protest  against  the  indiscriminate 
use  of  the  probe  in  the  exploration  of  fistulous  tracts  for  diag- 
nostic purposes.  Septic  infection  can  be  produced  not  only 
through  unclean  instruments,  but  by  means  of  the  most  care- 
fully-disinfected probe.  The  granulating  surfaces  exposed  to 
the  air  probably  have  upon  their  surfaces  harboring  places  for 
different  pathogenic  bacteria.  So  long  as  the  layer  of  granula- 
tions remains  intact  these  microbes  are  harmless ;  as  soon  as  the 
granulations  are  injured  the  lymphatic  spaces  are  opened,  into 
which  the  microbes  pass  and  infect  the  surrounding  tissues,  or, 
perchance,  the  general  system.  They  quickly  multiply  and 
initiate  progressive  septic  processes.  These  dangers  are  dimin- 
ished by  careful  disinfection  of  the  wound  as  well  as  of  the 
probe.  Cauterization  of  the  surface  with  nitrate  of  silver  pre- 
viously or  simultaneously  with  the  use  of  the  probe,  by  coating 


SYMPTOMS  AND  DIAGNOSIS  OF  TUBERCULAR  BONfi  AFFECTIONS.       107 

the  latter  with  the  melted  salt,  is  an  efficient  prophylactic  meas- 
ure. In  the  differential  diagnosis  of  tuberculosis  of  bone,  it  is 
necessary  to  exclude  synovial  tuberculosis,  sarcoma,  echinococ- 
cus  cyst,  rachitis,  suppurative  osteomyelitis,  conchiolin  osteomy- 
elitis, and  syphilis. 

Synovial  Tuberculosis. — Many  cases  of  synovial  tuberculo- 
sis have  been  mistaken  for  primary  bone  tuberculosis,  and  vice 
versa.  Primary  tuberculosis  of  bone  frequently  results  in  con- 
tractures  of  joints  without  direct  implication  of  the  joint,  and 
this  has  often  led  to  a  wrong  diagnosis.  In  primary  tuberculo- 
sis of  the  synovial  membrane,  the  first  pathological  changes 
occur  in  the  joint,  and  no  tender  points  will  be  found  in  the 
epiphysial  regions.  In  osteotuberculosis  not  complicated  by  an 
extension  of  the  disease  to  the  adjacent  joint,  the  first  symp- 
toms are  referred  to  the  lesion  existing  in  the  interior  of  the 
bone,  and  it  is  usually  not  difficult  to  ascertain  the  existence  of 
circumscribed  points  of  tenderness  which  correspond  to  the 
location  of  the  foci. 

Sarcoma. — Periosteal  sarcoma  is,  from  the  beginning,  an 
extra-osseous  product,  and  if  it  attack  the  shaft  of  a  long  bone 
it  displaces  the  soft  tissues  instead  of  infiltrating  them,  as  is  the 
case  in  tubercular  periostitis  following  primary  bone  tuberculo- 
sis. Central  osteosarcoma,  as  a  rule,  increases  more  rapidly  in 
size  than  a  tubercular  swelling,  and  is  often  the  seat  of  pulsa- 
tions on  reaching  the  surface  of  the  bone,  and  a  blowing  sound 
which  can  be  heard  by  auscultation.  Central  sarcoma  fre- 
quently gives  rise  to  a  pathological  fracture,  while  this  accident 
is  exceedingly  rare  in  osteotuberculosis. 

Echinococcus. — Echinococcus  of  bone  is  a  very  rare  affec- 
tion, but,  as  it  may  simulate  osteotuberculosis,  a  differential 
diagnosis  between  these  two  diseases  can  only  be  made  by  an 
exploratory  puncture,  which  will  yield  a  clear  serum  containing 
the  characteristic  booklets  in  the  former  instance,  and  granula- 
tion tissue  or  the  products  of  caseous  degeneration  in  the  latter. 

Rachitis. — Rachitis  is  a  disease  of  childhood,  and  is  char- 


108  TUBERCULOSIS   OP   THE   BONES    AND   JOINTS. 

acterized  by  swelling,  pain,  and  tenderness  in  the  epiphysial 
regions ;  but  this  affection  is  not  limited  to  one  or  two  bones, 
but  affects  alike  almost  every  bone  in  the  body.  Profuse  sweat- 
ing is  a  constant  symptom  of  rachitis,  but  seldom  present  in 
tubercular  inflammation  unattended  by  secondary  infection  with 
pus-microbes. 

Epiphysial  Multiple  Osteomyelitis. — This  is  an  acute  or,  at 
least,  subacute  affection,  and  results  early  in  the  formation  of 
purulent  foci,  and  is  often  attended  by  epiphyseolysis ;  with  the 
exception  of  the  upper  epiphysis  of  the  femur,  the  latter  con- 
dition is  seldom  met  with  in  osteotuberculosis.  The  joint  com- 
plication in  suppurative  osteomyelitis  is  of  the  same  nature  as 
the  primary  disease  in  reference  to  the  character  of  the  inflam- 
matory product. 

Conchiolin  Osteomyelitis. — Mother- of- pearl  osteomyelitis 
was  first  described  by  Englisch.  It  is  a  plastic  form  of  inflam- 
mation, and  is  caused  by  the  presence  of  pearl-dust  in  the  cap- 
illary vessels  of  the  epiphysial  extremities  of  the  long  bones  in 
persons  employed  in  the  manufacture  of  articles  of  pearl.  In  a 
valuable  paper  on  this  subject  Gussenbauer  ("  Die  Knochen- 
entziindung  der  Perl-mutterdrechsler."  Archiv  f.  Idinische 
Chirurgie,  B.  xviii)  describes  the  entrance  of  pearl-dust  into 
the  circulation,  and  the  manner  in  which  the  inflammation  is 
produced.  The  artisans  inhale  the  fine  dust,  which,  in  part, 
enters  the  pulmonary  tissue  in  the  same  manner  as  fine  coal- 
dust  or  microbes, — through  the  mucous  membrane  of  the  bron- 
chial tubes.  In  the  lungs  minute  particles  of  dust  aggregate 
in  small  foci  and  excite  slight  inflammation  around  them.  The 
dust  is  composed  chemically  of  CO2Ca()  and  conchiolin.  In 
the  lungs  the  CO2CaO  is  dissolved,  and  conchiolin  remains  as 
an  insoluble  substance.  This  substance  enters  the  circulation 
and  collects  in  the  capillaries  of  the  medullary  tissue  in  the 
epiphysial  region  of  the  long  bones,  and  leads  to  obliteration 
of  some  of  the  fine  arterial  branches.  The  osteomyelitis  which 
develops  around  the  infarcts  spreads  by  continuity  to  the  sur- 


SYMPTOMS  AND    DIAGNOSIS  OF   TUBERCULAR  BONE  AFFECTIONS.       109 

rounding  bone,  periosteum,  and  joints.  The  inflammatory 
product  is  of  a  plastic  type ;  resolution  and  recovery  follow,  as 
a  rule.  Only  in  one  case  did  the  disease  terminate  in  suppura- 
tion, and  in  this  instance  the  primary  conchiolin  osteomyelitis 
undoubtedly  became  the  seat  of  infection  with  pus-microbes. 

SypftUi*. — The  virus  of  syphilis  has  a  special  predilection 
for  the  periosteum,  while  this  structure  is  not  very  susceptible 
to  primary  tubercular  infection.  As  a  hereditary  affection, 
syphilitic  osteomyelitis  of  the  epiphyses  is  not  infrequently  met 
witli  in  newborn  infants  and  young  children. 

Birch-Hirschfeld  ("  Beitrage  zur  pathologischen  Anatomic 
der  hereditaren  Syphilis  Neugeborner  Kinder,"  etc.  Arcldv 
der  Heilkunde,  Heft  2,  1875)  found  the  characteristic  patho- 
logical changes  indicative  of  syphilitic  inflammation  of  bone  in 
thirty-five  out  of  one  hundred  and  eight  stillborn  children. 

Haab  ("  Zur  Kenntniss  der  syphilitischen  Epiphysen- 
losung."  Virchow's  Arcliiv,  B.  Ixv,  Heft  3,  p.  366)  examined 
the  conditions  of  syphilitic  disease  of  the  epiphysial  extremities 
of  the  long  bones  in  two  stillborn  children.  In  both  of  these 
cases  epiphyseoh  sis  had  taken  place,  and  the  most  striking 
pathological  conditions  were  found  in  the  epiphysial  cartilages. 
In  one  of  the  cases  the  intercellular  substance  had  undergone 
molecular  destruction,  while  in  the  other,  the  condition  pointed 
to  an  irritation  which  had  given  rise  to  active  proliferation  of 
the  cartilage  cells. 

Taylor  ("  Syphilitic  Lesions  of  the  Osseous  System  in 
Infants  and  Young  Children,"  p.  173)  has  written  very  clearly 
and  precisely  on  the  differential  diagnosis  between  syphilitic 
and  tubercular  affections  of  bone. 

"  An  important  question  here  arises,  namely :  Are  there 
any  distinguishing  characteristics  in  the  osseous  lesions  which 
will  enable  the  physician  to  promptly  and  correctly  diagnosti- 
cate them  from  syphilis]  It  must  be  confessed  that,  in  the 
main,  they  resemble  in  many  particulars  the  lesion  of  syphilis; 
still,  there  are  certain  quite  distinct  features  which  are  important 


110  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

to  know.  As  a  rule,  the  osseous  lesions  above  alluded  to  (those 
of  acquired  struma)  are  developed  rather  rapidly,  may  be  com- 
plicated early  by  degeneration,  and,  for  the  most  part,  do  not 
primarily  affect  the  joints.  There  are  usually  a  smaller  number 
of  bones  involved  than  in  syphilis,  and  there  is  a  greater  ten- 
dency to  unsymmetrical  development.  Pain  is  generally  a  con- 
stant symptom,  and,  in  short,  there  is  usually  a  much  more 
pronounced  condition  of  inflammation  than  we  find  in  syphilis. 
When  degeneration  occurs,  there  may  follow  sinuses  which 
have  the  typical  scrofulous  appearance,  which  we  have  observed 
to  be  not  constant  in  syphilis.  Finally,  a  point  of  some  impor- 
tance may  be  determined  by  the  bone  or  bones  involved ;  thus, 
in  this  condition,  it  is  very  probable  that  the  cranial  bones 
would  be  unaffected,  and  that  the  lesion  would  be  limited  gen- 
erally to  the  long  bones  or,  perhaps,  to  the  phalanges ;  whereas, 
in  syphilis  we  have  found  that  a  number  of  different  classes  of 
bones  were  often  coincidently  involved.  Still,  as  I  have  said 
in  the  chapter  on  diagnosis,  the  distinction  very  often  rests  upon 
the  history  of  the  case  and  upon  the  co-existence  of  lesions  which 
are  undoubtedly  syphilitic.  Treatment  will  not  always  afford 
conclusive  evidence,  but  it  may  sometimes  assist  in  a  measure." 
In  doubtful  cases,  in  which  the  results  of  treatment  do  not 
furnish  positive  diagnostic  information,  it  may  become  necessary 
to  resort  to  inoculation  experiments  in  settling  the  diagnosis 
between  syphilitic  and  tubercular  affections  of  bone. 


CHAPTER  XII. 

PROGNOSIS  OF  TUBERCULAR  DISEASE  OF  BONE. 

ON  the  whole,  the  prognosis  is  more  favorable  in  osteo- 
tuberculosis  than  if  the  tubercular  infection  is  located  in  the 
skin,  a  joint,  lymphatic  gland,  or  any  of  the  internal  organs. 
Spontaneous  healing  of  a  tubercular  focus  in  bone  is  possible 
under  favorable  conditions.  Everything  that  adds  to  the 
patient's  strength  and  power  of  resistance  to  the  microbic  infec- 
tion adds  to  the  possibility  of  such  favorable  termination.  If 
the  patient  is  well  nourished,  and,  above  all,  if  the  blood  is  in 
a  normal  condition,  limitation  of  the  disease  may  occur  before 
caseation  has  taken  place;  and,  if  cheesy  material  has  formed, 
and  can  be  removed  by  operative  interference,  the  prospects  of 
a  permanent  recovery  are  good.  It  must  be,  however,  admitted 
that  every  person  who  has  suffered  from  an  attack  of  osteotuber- 
culosis  during  childhood  or  youth,  even  if  an  apparent  perfect 
cure  has  been  effected  spontaneously  or  by  operative  measures, 
is  always  in  danger  of  becoming  the  subject  of  re-infection  at 
any  subsequent  time.  The  spores  of  the  bacillus  of  tuberculosis 
may  remain  in  a  latent  condition  for  an  indefinite  period  of 
time  in  the  cicatrized  primary  lesion,  to  become  a  cause  of  sub- 
sequent danger  as  soon  as  the  local  or  general  conditions  enable 
them  to  develop  and  exercise  their  specific  pathogenic  proper- 
ties. Healing  by  cicatrization  is  possible  in  the  small  granulat- 
ing foci,  so  long  as  the  coagulation  necrosis  is  limited  and  no 
caseation  has  occurred.  In  such  cases  the  embryonal  cells  are 
converted  into  permanent  connective  tissue  or  bone,  and  the 
small  fragments  of  bone  are  removed  by  absorption,  while  the 
bone  around  the  cicatrix  undergoes  sclerosis.  If  caseation  has 
occurred,  and  the  cheesy  material  has  not  undergone  liquefac- 
tion, encapsulation  of  the  tubercular  product  can  take  place  by 
the  wall  of  granulation  tissue  lining  the  cavity  becoming  con- 
verted into  cicatricial  tissue,  forming  a  capsule,  which,  for  the 

(111) 


112  TUBERCULOSIS   OF   THE   BONES    AND    JOINTS. 

time  being  at  least,  mechanically  prevents  the  local  extension 
of  the  disease.  Small  sequestra  may  become  imbedded  in  a 
connective-tissue  capsule  in  a  similar  manner.  Osteosclerosis 
around  a  healed  tubercular  focus  adds  an  additional  barrier  to 
local  extension  and  general  infection.  If  the  sequestrum  is 
large,  it  will  behave  like  every  other  foreign  infected  body,  and 
sooner  or  later  require  an  operation  for  its  extraction.  The  ap- 
pearance of  tuberculosis  in  several  bones  simultaneously  or  in 
succession  render  the  prognosis  much  more  unfavorable  than  in 
cases  in  which  the  infection  is  limited  to  a  single  bone.  If  the 
tubercular  process  has  extended  to  a  joint  the  prognosis  is  also 
more  grave,  and  the  chances  of  a  spontaneous  recovery  are  much 
lessened.  The  prognosis  is  always  more  serious,  other  things 
being  equal,  if  the  bone  affected  is  so  located  that  elimination 
of  the  tubercular  product  is  rendered  difficult,  and  the  removal 
of  the  primary  focus  by  operative  treatment  is  anatomically  im- 
possible. The  danger  to  life  and  the  probability  of  local  exten- 
sion are  always  greater  if  the  granulation  tissue  has  been 
destroyed  by  coagulation  necrosis  and  caseation,  as  the  granula- 
tion tissue  is  one  of  the  means  by  which  regional  and  general 
infection  are  prevented.  The  danger  to  life  is  imminent  if  a 
large  tubercular  abscess  has  become  infected  with  pus-microbes, 
as  the  secondary  infection  results  in  destruction  of  the  granula- 
tion tissue  lining  the  cavity, — a  condition  which  favors  the  local 
and  general  extension  of  the  tubercular  infection,  and  at  the 
same  time  brings  sepsis,  exhaustion  from  profuse  suppuration, 
and  amyloid  degeneration  of  important  internal  organs  as  addi- 
tional elements  of  danger.  The  prognosis  is  always  more  un- 
favorable in  persons  advanced  in  years  than  in  children,  as 
limitation  of  the  disease  occurs  more  frequently  in  the  latter. 

Bone  tuberculosis  leads,  in  a  certain  percentage  of  cases,  to 
infection  of  distant  organs  and  general  miliary  tuberculosis. 
Re-infection  of  the  body  from  a  tubercular  focus  in  bone  takes 
place  either  directly  through  the  veins  or  indirectly  through  the 
lymphatic  channels.  In  young  children  tubercular  meningitis 


PROGNOSIS   OF   TUBERCULAR   DISEASE   OF   BONE.  113 

and  general  miliary  tuberculosis  often  occur  without  any  affec- 
tion of  the  lymphatic  glands  on  the  proximal  side  of  the  focus, 
and  in  such  cases  the  infection  undoubtedly  takes  place  by  the 
entrance  of  bacilli  or  small  fragments  of  infected  tissue  into  the 
venous  circulation.  Very  often,  however,  it  can  be  seen  that 
tuberculosis  of  an  extremity  diffuses  itself  through  the  body  and 
becomes  general  through  the  lymphatic  channels.  Tubercular 
affections  of  the  hand  not  infrequently  give  rise  to  similar  affec- 
tions of  the  cubital  and  axillary  lymphatic  glands.  Quite  as 
often  tuberculosis  of  the  knee  and  foot  is  followed  by  similar 
lesions  of  the  inguinal  glands,  while  tubercular  coxitis  gives  rise 
to  infection  of  the  pelvic  glands.  If  such  glands  are  examined 
after  extirpation,  they  always  show  the  characteristic  appear- 
ances of  tuberculosis  of  these  organs.  Sometimes  regional  and 
general  infection  takes  place  by  extension  of  the  disease  to  a 
serous  membrane;  for  instance,  in  cases  of  coxitis,  where  the 
disease  has  resulted  in  perforation  of  the  acetabulum,  the  pelvic 
connective  tissue  is  first  infected,  later  the  peritoneum  is  reached, 
and  finally  the  patient  dies  of  general  miliary  tuberculosis. 
Similar  observations  have  been  made  in  connection  with  tuber- 
culosis of  the  vertebrae,  sternum,  and  ribs. 

The  duration  of  the  disease  is  an  important  matter,  from 
a  prognostic  view.  Spontaneous  cures  have  been  observed  both 
in  primary  and  secondary  tuberculosis  of  bone.  By  cicatricial 
cpntraction  the  local  focus  is  eliminated  or  rendered  harmless. 
Large,  wedge-shaped  sequestra  furnish  an  insurmountable  bar- 
rier to  definitive  local  healing  without  surgical  interference. 
An  apparently  healed  focus  may  remain  harmless  and  latent 
for  years,  but  later  it  can  serve  again  as  the  starting-point  of  a 
new  attack.  Bone-lesions  consisting  of  firm,  dry  granulations, 
without  a  tendency  to  caseation,  terminate,  under  favorable 
circumstances,  in  recovery  in  from  two  to  three  years.  Suppu- 
ration does  not  always  affect  the  prognosis  unfavorably.  Small 
abscesses  in  bones  and  joints,  in  which  otherwise  the  conditions 
of  the  granulations  are  favorable,  heal  by  cicatrization,  either 


114  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

after  spontaneous  or  artificial  removal  of  their  contents  or  by 
inspissation  and  encapsulation  of  the  inflammatory  product. 
The  duration  of  osteotuberculosis  is  variable,  and  cannot  be 
estimated  with  any  degree  of  certainty,  for  without  sponta- 
neous or  surgical  removal  of  the  tubercular  tissue  the  local 
focus  is  always  a  source  of  danger.  Amyloid  degeneration  of 
important  internal  organs  only  takes  place  after  the  tubercular 
lesion  has  become  the  seat  of  a  chronic  suppurative  process. 
The  last  and  greatest  danger  attending  bone  and  joint  tuber- 
culosis is  acute  miliary  tuberculosis.  The  tubercular  embolus 
which  blocks  a  small  artery  in  wedge-shaped,  tubercular  infarct 
of  the  epiphysial  extremities  of  the  long  bones  must  have 
passed  through  the  heart,  as  it  is  not  probable  that  it  ever  enters 
the  arterial  system  directly.  Such  emboli  are  undoubtedly 
derived  most  frequently  from  tubercular  thrombi  in  the  pulmo- 
nary veins  in  the  immediate  vicinity  of  tubercular  foci  in  the 
lungs.  In  all  other  instances  the  bacilli  must  pass  the  pulmo- 
nary capillary  vessels.  As  it  is  not  possible  for  fragments  of 
tubercular  tissue  of  any  considerable  size  to  pass  through  the 
pulmonary  capillaries,  it  is  probable  that  the  embolus  is  com- 
posed of  a  small  mass  of  bacilli,  tied  together  with  fibrin. 
Perhaps,  also,  a  colony  of  bacilli  aggregate  at  the  point  of 
bifurcation  of  a  small  artery  in  bone  by  mural  implantation, 
and  in  this  manner  a  tubercular  thrombus  is  gradually  formed, 
which  completely  obstructs  the  circulation  to  the  area  of  bone 
supplied  by  the  blocked  vessel.  In  miliary  tuberculosis  millions 
of  bacilli  gain  entrance  into  the  circulation  from  a  tubercular 
focus  and  localize  in  various  organs,  each  point  of  localization 
becoming  a  miliary  nodule.  Konig  has  observed  this  termina- 
tion only  sixteen  times  out  of  thousands  of  cases  of  bone  and 
joint  tuberculosis  that  have  come  under  his  personal  observation. 
In  all  of  these  cases  the  general  tuberculosis  followed  operations 
for  tubercular  lesions.  Miliary  diffuse  tuberculosis  may  and 
does  occur  without  such  an  immediate  cause.  I  have  observed 
tubercular  meningitis  develop  in  young  children  on  several 


PROGNOSIS   OF   TUBERCULAR   DISEASE   OF   BONE.  115 

occasions,  in  the  course  of  tubercular  coxitis,  without  operative 
treatment,  which  shows  that  a  tubercular  focus  in  bone,  undis- 
turbed by  operation,  may  become  the  distributing-point  of 
bacilli,  and  constitute  the  immediate  cause  of  metastatic  tuber- 
culosis in  another  organ,  or  general  miliary  tuberculosis. 


CHAPTER  XIII. 

TREATMENT  OF  TUBERCULOSIS  OF  BONE. 

EARLY  effective  treatment  of  tubercular  affections  of  bone 
is  of  the  greatest  importance,  because  the  intrinsic  tendency  of 
the  disease  is  toward  progressive  extension,  and,  if  left  to  itself, 
sooner  or  later  the  appearance  of  serious  complications  is  the 
rule,  spontaneous  recovery  the  exception.  In  some  bones  of 
the  body  the  disease  can  be  thoroughly  eradicated  by  a  simple 
and  safe  operation ;  in  others,  the  anatomical  location  of  the 
disease  is  such  that  a  radical  operation  is  out  of  question.  As 
illustrations  of  the  former  class  of  cases,  it  is  sufficient  to  men- 
tion tuberculosis  of  the  phalanges  of  the  hands  and  feet  and 
of  the  malar  bones,  and,  as  an  instance  of  the  latter,  the  bodies 
of  the  vertebrae.  The  medical  treatment  in  patients  suffering 
from  osteotuberculosis  must  be  tonic  and  supporting.  Dietetic 
and  hygienic  treatment  is  of  more  importance  and  value  than 
the  administration  of  drugs.  Sea-bathing  and  change  of 
climate  will  often  accomplish  more  than  bitter  tonics,  iron, 
quinine,  arsenic,  and  codliver-oil.  Experimental  research  has 
demonstrated  that  the  internal  and  subcutaneous  employment 
of  some  of  the  preparations  of  iodine  retards  the  development 
and  reproduction  of  the  bacillus  of  tuberculosis  in  animals  in 
which  the  disease  was  produced  artificially,  and  experience  has 
shown  that  the  same  preparations  can  be  advantageously  used 
in  the  treatment  of  different  forms  of  surgical  tuberculosis, 
including  osteotuberculosis.  A  combination  of  potassic  iodide 
with  the  syrup  of  iodide  of  iron  has,  in  my  experience,  pro- 
duced better  results  than  any  other  method  of  medication.  If 
digestion  is  not  impaired,  this  medicine  should  be  given  in 
gradually  increasing  doses,  until  the  iodine  has  produced  its 
physiological  effect,  when  the  use  of  the  drug  is  not  suspended, 
but  the  dose  reduced.  The  internal  use  of  creasote,  which 
seems  to  have  proved  of  some  benefit  in  the  treatment  of  pul- 
(116) 


TREATMENT  OF  TUBERCULOSIS  OF  BONE.         H7 

monary  tuberculosis,  deserves  a  trial  in  the  treatment  of  bone 
and  joint  tuberculosis.  Children  suffering  from  osteotubercu- 
losis  should  be  carefully  dressed,  and  the  deleterious  effect  of 
sudden  changes  of  temperature  guarded  against  by  enforcing 
the  wearing  of  flannel  under-clothing.  Out-door  air  and  a 
certain  amount  of  exercise  should  be  procured  whenever  the 
local  disease  does  not  furnish  a  positive  contra-indication.  Salt- 
water baths  are  of  great  value  in  such  cases,  as  they  stimulate 
the  peripheral  circulation,  and,  in  so  doing,  prevent  internal 
congestions.  The  local  treatment,  short  of  a  radical  operation, 
must  consist  in  the  use  of  such  measures  as  will  aid  nature's 
resources  in  effecting  limitation  of  the  tubercular  process,  of 
which  one  of  the  most  important  is 

Physiological  Rest. — The  importance  of  securing,  as  nearly 
as  can  be  done  by  position  and  mechanical  support,  physio- 
logical rest  for  the  inflamed  part  cannot  be  overestimated. 
The  process  of  repair  in  a  tubercular  focus  often  meets  with 
great  and  insurmountable  difficulties.  The  embryonal  cells,  of 
low  vitality  almost  from  the  very  beginning,  are  poisoned,  as 
soon  as  born,  with  the  ptomaines  of  the  bacillus  of  tuberculosis, 
and  consequently  are  converted  into  tissue  of  a  higher  type 
only  under  the  most  favorable  circumstances.  The  non-vascu- 
larity  of  tubercle-tissue  is  another  cause  why  the  inflammatory 
product  so  seldom  takes  an  active  part  in  the  process  of  repair. 
The  first  indication  in  the  treatment  of  a  tubercular  osteo- 
myelitis is  to  secure  for  the  part  a  favorable  condition  of  the 
circulation,  which  can  only  be  accomplished  by  rest.  The  most 
efficient  way  to  procure  rest,  not  only  for  the  diseased  part,  but 
for  the  entire  body,  is  to  confine  the  patient  to  bed ;  but,  as 
these  affections  are  noted  for  their  chronicity  lasting  for  months 
and  years,  enforced  rest  by  this  method  would  seriously  impair 
the  general  health,  and  the  benefit  derived  from  it  for  the  local 
lesion  would  be  more  than  overbalanced  by  the  lack  of  fresh 
air  and  out-door  exercise,  and,  on  this  account,  it  is  advisable, 
in  the  majority  of  cases,  to  resort  to  one  of  the  numerous  me- 


118  TUBERCULOSIS  OP   THE   BONES  AND  JOINTS. 

chanical  appliances  which  will  immobilize  the  part ;  while,  at 
the  same  time,  the  patient  can  avail  himself  of  the  benefits  to 
be  gained  from  out-door  air,  change  of  scenery  and  surround- 
ings. In  tuberculosis  of  the  spine  it  is  often  advisable  to 
confine  the  patient  to  bed  upon  a  Rauchfuss  swing  until  the 
more  acute  symptoms  have  subsided,  and,  later,  apply  Sayre's 
plaster-of-Paris  dressing.  This  method  of  making  extension 
and  of  securing  immobilization  answers  a  better  purpose  than 
any  of  the  numerous  complicated  apparatuses  which  have  been 
as  yet  devised.  To  apply  the  jacket  properly  requires  a  great 
deal  of  experience  and  the  exercise  of  considerable  skill.  In 
many  communities  this  method  of  treatment  has  become 
unpopular,  both  among  the  physicians  and  the  laity,  from  the 
bad  results  caused  by  improper  application  of  the  jacket  and 
faulty  extension.  Hyperextension  must  be  avoided,  and  the 
patient  must  be  instructed  to  extend  himself  until  he  experi- 
ences relief,  and  no  further.  When  this  point  has  been  reached 
the  spine  is  immobilized  in  a  plaster-of-Paris  cast.  Immobili- 
zation of  joints  with  osseous  foci  in  their  vicinity  is  accom- 
plished most  effectually  by  the  same  kind  of  dressing. 

Parenchymatous  Injections. — The  direct  treatment  of  a 
tubercular  focus  in  bone  by  the  injection  of  antibacillary  reme- 
dies fulfills  the  etiological  indication.  The  success  which  has 
followed  t.he  injection  of  tubercular  joints  with  iodoform  and 
other  antitubercular  remedies  should  induce  the  surgeons  to 
give  this  method  a  thorough  trial  in  the  early  treatment  of 
osteotuberculosis.  I  have  recently  made  a  number  of  such 
injections  into  the  neck  of  the  femur  in  cases  of  coxitis  with 
osseous  foci,  and  with  results  that  encourage  me  to  continue 
this  method  of  treatment.  A  10-per-cent.  emulsion  of  iodo- 
form or  balsam  of  Peru  should  be  employed  for  this  purpose. 
This  treatment  will  undoubtedly  prove  of  great  value  in  the 
treatment  of  granulating  foci  before  caseation  has  occurred.  If 
the  parenchymatous  injections  are  successful  in  sterilizing  the  in- 
fected tissue  there  is  nothing  further  in  the  way  of  the  inaugura- 


TREATMENT  OF  TUBERCULOSIS  OF  BONE.         119 

tion  of  a  reparative  process ;  at  the  same  time,  further  local  and 
general  infection  need  no  longer  be  feared.  If  an  osseous  focus 
in  one  of  the  epiphysial  extremities  of  the  long  bones  can  be 
located  accurately  the  product  of  the  tubercular  inflammation 
can  be  easily  reached  and  saturated  with  the  iodoform  emulsion. 
The  parenchymatous  injection  should  be  made  with  a  large 
exploring  syringe,  with  an  asbestos  instead  of  an  ordinary 
leather  piston.  The  needle  should  be  stout,  and  sufficiently 
long  to  reach  deep-seated  foci.  The  strictest  antiseptic  precau- 
tions must  be  observed.  The  focus  must  be  located  as  accu- 
rately as  possible,  and  the  puncture  made  in  the  manner  pre- 
viously described.  From  one  drachm  to  half  an  ounce  of  the 
emulsion  is  to  be  injected ;  the  injection  of  the  latter  quantity 
can  only  be  made  by  using  considerable  pressure  and  proceeding 
with  the  injection  very  slowly,  in  order  to  gain  time  for  the 
fluid  to  permeate  the  tubercular  tissue  in  all  directions.  The 
iodoform  not  only  possesses  potent  inhibitory  antibacillary  prop- 
erties when  employed  in  this  manner,  but  at  the  same  time 
stimulates  the  tissues  around  the  infected  area  to  active  tissue- 
proliferation,  which  cannot  fail  in  favoring  the  process  of  limita- 
tion and  in  expediting  the  reparative  process.  The  injection 
should  be  repeated  every  two  weeks,  and  is  to  be  made  from  a 
different  point  every  time,  in  order  to  saturate  gradually  the 
focus  throughout  with  the  antibacillary  substance.  The  anti- 
tubercular  action  of  iodoform  is  sufficiently  well  established  by 
experimental  research  and  clinical  experience  to  warrant  a 
trial  with  this  remedy  in  the  early  stages  of  bone  tuberculosis. 
Hueter  advised  parenchymatous  injections  of  a  5-per-cent.  solu- 
tion of  carbolic  acid,  and,  more  recently,  solutions  of  corrosive 
sublimate  have  been  used,  but  the  results  obtained  with  either 
of  these  remedies  are  less  favorable  than  those  following  paren- 
chymatous injections  of  a  10-per-cent.  emulsion  of  iodoform  in 
glycerin  or  pure  olive-oil.  Whether  it  is  the  iodoform  as  such 
which  produces  the  curative  effects,  or  whether  it  is  the  formic 
acid,  as  some  claim,  which  is  one  of  the  products  of  the  de- 


120  TUBERCULOSIS  OF   THE  BONES  AND  JOINTS. 

composition  of  the  iodoform  in  the  tissues,  is  immaterial  from  a 
practical  stand-point.  I  have  not  found  it  difficult  to  inject 
into  tubercular  osseous  foci  from  one-half  to  one  ounce  of  the 
emulsion,  provided  the  injection  is  made  slowly  and  a  requisite 
number  of  deep  punctures  are  made.  The  injection  should  be 
repeated  every  two  weeks,  and  during  the  intervals  the  remain- 
ing part  of  the  treatment  so  adapted  as  to  place  the  affected 
part  in  the  most  favorable  condition  for  the  reparative  process. 

Ignipuncture. — Deep  cauterization  was  introduced  by  Richet 
as  a  therapeutic  resource  in  the  treatment  of  bone  and  joint 
tuberculosis  in  1870.  ("  De  1'ignipuncture  ou  de  la  cauteriza- 
tion profonde  avec  dcs  pointes  de  fer  rouge  dans  le  traitement 
des  Arthropathies  chroniques  et  des  fungosites  synovialis," 
Presse  Ned,  Beige,  No.  29,  1870.)  The  instrument  used  first 
was  an  ordinary  cautery  iron  with  a  bulbous  extremity,  and  to 
the  bulb  was  attached  a  short  platinum  point,  two  to  three 
centimetres  in  length,  like  the  needle-point  of  a  Paquelin 
cautery.  The  instrument  was  heated  in  the  ordinary  manner, 
and  the  sharp  point  was  plunged  into  the  tissues  far  enough  to 
reach  the  interior  of  the  diseased  joint 'or  the  focus  in  bone. 
The  bulb  was  relied  upon  to  furnish  the  necessary  heat  during 
the  time  required  to  make  the  puncture.  He  made  from  two  to 
twenty-four  punctures  at  one  sitting,  the  number  of  the  punc- 
tures being  regulated  by  the  size  of  the  joint  or  bone  and  the 
extent  of  the  intra-articular  or  osseous  lesion.  He  applied  the 
procedure,  which  he  designates  ignipuncture,  in  the  treatment 
of  chronic  inflammation  of  bone  and  joints.  The  reaction  fol- 
lowing the  operation  is  usually  slight,  and  the  after-treatment 
consisted  of  cold  applications  to  the  part  operated  on. 

Kocher  ("Zur  Prophylaxis  der  fungosen  Gelenkentziindung 
mit  besonderer  Beriicksichtigung  der  chronischen  Osteomyelitis 
und  ihrer  Behandlung  mittelst  Ignipunctur,"  Volkmann's  Klin- 
Ische  Vortraye,  No.  102)  employed  ignipuncture  in  the  treatment 
of  chronic  osteomyelitis  in  1872,  before  he  had  heard  of  Richet's 
work.  He  used  a  similar  instrument,  but  with  a  longer  platinum 


TREATMENT  OF  TUBERCULOSIS  OF  BONE.         121 

point.  The  cautery,  heated  to  a  white  heat,  was  pushed  through 
the  intact  skin  and  softened  bone  into  the  osseous  focus.  Of 
eighteen  cases  treated  in  this  manner,  most  of  them  made  a 
rapid  recovery ;  in  others  the  cure  was  more  protracted.  One 
case  died  of  pulmonary  phthisis,  the  fistulous  opening  made 
with  the  cautery  remaining  open ;  two  cases  remained  under 
observation  at  the  time  the  report  was  made. 

In  opposition  to  Richet  and  Juillard,  Kocher  maintains 
that  ignipuncture  should  be  done  in  recent  cases,  and  especially 
as  a  prophylactic  measure  when  an  osseous  focus  threatens  to 
invade  an  adjacent  joint.  In  such  cases  Kocher  regards  igni- 
puncture both  as  a  curative  and  prophylactic  measure,  as,  when 
it  is  resorted  to  early  and  properly,  it  not  only  often  cures  the 
primary  lesion  in  the  bone,  but  at  the  same  time  prevents  the 
extension  of  the  disease  to  the  joint.  It  is  interesting  to  know 
that  ignipuncture,  in  the  hands  of  Richet,  Kocher,  and  others, 
yielded  such  happy  results  at  a  time  when  the  operation  was 
performed  without  antiseptic  precautions.  Invasion  of  tubercu- 
lar foci  with  the  knife  at  that  time  could  not  present  such  a 
favorable  showing.  This  difference  in  the  results  was,  of  course, 
owing  to  the  fact  that  in  the  former  procedure  the  tissues  were 
protected  against  infection  from  the  tubercular  focus  within  and 
the  pathogenic  microbes  from  without  by  the  tubular  eschar 
lining  each  one  of  the  punctures.  Ignipuncture,  when  prac- 
ticed under  antiseptic  precautions,  is  a  perfectly  safe  procedure, 
and  a  timely  resort  to  it  in  cases  of  primary  osseous  tuberculosis 
will  often  be  the  means  of  preventing  joint  complications,  and 
render  more  serious  and  mutilating  operations  unnecessary.  Its 
use  should  be  limited  to  the  early  treatment  of  osseous  tubercu- 
losis and  tubercular  affections  of  small  joints.  It  should  no 
longer  be  used  in  tuberculosis  of  the  large  joints.  The  benefits 
from  ignipuncture  are  most  marked  when  used  before  the  tuber- 
cular product  lias  undergone  caseation  ;  it  is,  therefore,  most 
applicable  during  the  early  stage  of  bone  tuberculosis.  The 
instrument  that  is  now  used  exclusively  for  this  purpose  is  a 


122  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

Paquelin  cautery.  If  an  accessible  tubercular  focus  can  be 
accurately  located  in  the  interior  of  a  bone  this  method  of  treat- 
ment should  receive  a  trial,  as  it  is  not  attended  by  any  risks, 
and  frequently  effects  a  permanent  cure.  The  field  of  opera- 
tion is  thoroughly  disinfected,  and,  with  the  needle-point  of  a 
Paquelin  cautery  heated  to  a  dull-red  heat,  the  soft  tissues  and 
bone  are  perforated.  The  compact  bone  over  a  tubercular  focus 
has  usually  undergone  such  a  degree  of  softening  that  it  can  be 
penetrated  without  much  difficulty.  In  making  the  puncture 
it  is  necessary  to  advance  the  point  slowly  and  to  remove  it  from 
time  to  time,  and  revive  the  heat,  in  order  to  prevent  impaction 
of  the  point.  The  entrance  of  the  point  of  the  instrument 
into  the  cavity  or  tubercular  focus  can  be  readily  felt,  as  resist- 
ance at  that  moment  is  suddenly  diminished.  The  therapeutic 
effect  of  ignipuncture  is  threefold:  (1)  the  tunnel  made  estab- 
lishes free  drainage,  and  relieves  promptly  the  intra-osseous 
tension ;  (2)  the  whole  or,  at  least,  a  portion  of  the  infected  tis- 
sue is  destroyed  by  the  heat ;  (3)  a  plastic  osteomyelitis  is  ex- 
cited in  the  vicinity  of  the  track  made  by  the  cautery,  and  in 
the  cauterized  portion  of  the  cavity,  which  exercises  a  favorable 
influence  in  bringing  about  limitation  of  the  disease,  or  even 
effecting  a  final  cure.  Through  the  opening  made  iodoform 
can  be  introduced  into  the  cavity,  which  offers  an  additional 
advantage  in  treating  osseous  foci  successfully  by  this  procedure. 
If  the  tubercular  focus  is  large,  that  is,  larger  than  a  hazel-nut, 
multiple  punctures  in  different  directions  can  be  made  through 
the  same  external  opening,  so  as  to  destroy  as  much  as  possible 
of  the  infected  tissue.  To  insure  a  successful  issue  it  is  abso- 
lutely necessary  to  prevent  infection  with  pus-microbes  through 
the  opening  by  making  the  operation  under  strict  antiseptic 
precautions  and  protecting  the  external  opening  with  an  efficient 
antiseptic  absorbent  dressing  until  it  is  completely  closed  by 
cicatrization  and  epidermization.  Ignipuncture  is  most  useful 
in  the  treatment  of  accessible  foci  in  the  epiphysial  extremities 
of  the  long  bones  and  during  the  early  stages  of  tuberculosis 


TREATMENT  OF  TUBERCULOSIS  OF  BONE.         123 

of  the  wrist  and  tarsus.  In  incipient  tuberculosis  of  the  tarsus 
I  have  repeatedly  obtained  a  satisfactory  and  permanent  result 
by  making  an  opening  through  the  entire  tarsus  from  side  to 
side,  in  a  line  of  the  disease,  by  inserting  the  point  from  each 
side,  the  two  tunnels  meeting  in  the  centre.  Ignipuncture 
always  relieves  the  pain  promptly,  and  the  track  made  is  care- 
fully closed  by  permanent  tissue  in  the  course  of  a  few  weeks. 

Removal  of  Osseous  Tubercular  Foci  by  Chiseling  and 
Evidement. — While  ignipuncture  and  parenchymatous  injec- 
tions of  iodoform  are  only  applicable  in  the  treatment  of  bone 


FIG.  20.— FISTULA  OVER  MIDDLE  OF  TROCHANTER  MAJOR,  LEADING  INTO  THK 
NECK  OF  THE  FEMUR,  IN  A  GIRL  TWELVE  YEARS  OLD.    (Volkmann.) 

Fistulous  tract  was  enlarged  with  chisel,  and  four  sequestra  and  granulations  removed.    Perfect  use  of  joint. 

tuberculosis  before  the  inflammatory  product  has  undergone 
extensive  caseation  or  sequestration,  the  mechanical  removal  of 
the  infected  tissue  is  indicated  in  all  stages  of  the  disease,  and 
should  always  be  done  before  the  adjacent  joint  is  invaded. 
The  great  danger  to  a  joint,  and  the  possibility  of  removing 
the  osseous  focus  without  opening  the  joint,  is  well  shown  in 
Fig.  20.  The  radical  treatment  of  tuberculosis  of  bone  con- 
sists in  the  complete  removal  of  the  infected  tissues  by  opera- 
tive interference.  The  success  which  follows  this  method  of 
treatment  is  most  marked  in  cases  where  caseation  has  not 


124  TUBERCULOSIS   OP   THE   BONES  AND  JOINTS. 

taken  place, — that  is,  in  the  granulating  form,  and  in  other 
forms  where  the  operation  is  performed  before  extensive  second- 
ary pathological  conditions  have  occurred.  The  operation  of 
exposing  a  tubercular  osseous  focus  with  the  chisel  and  remov- 
ing the  infected  tissues  with  a  sharp  spoon  is  indicated  as  soon 
as  a  positive  diagnosis  can  be  made,  and  after  milder  measures 
have  proved  useless  in  arresting  the  progress  of  the  disease. 
Timely  surgical  interference  in  osteotuberculosis  is  not  only  cal- 
culated to  become  the  surest  means  of  preventing  general  infec- 
tion, but  it  also  has  for  its  object  the  limitation  of  the  disease 
by  the  removal  of  the  primary  cause  ;  and  by  accomplishing 
these  objects  it  becomes  at  once  a  prophylactic  as  well  as  a 
curative  measure.  If  a  tubercular  focus  or  foci  can  be  removed 
by  a  radical  operation  before  the  adjacent  joint  has  become 
infected,  then  the  operation  has  not  only  been  successful  in 
effecting  a  permanent  cure,  but  it  has  also  been  instrumental  in 
preventing  the  extension  of  the  disease  to  the  joint. 

If  the  operation  is  undertaken  at  a  time,  as  it  should  be, 
before  any  external  swelling  has  appeared,  the  surgeon  must  be 
guided  in  finding  the  focus  by  searching  for  tender  points, 
aided,  if  necessary,  by  exploratory  punctures.  As  in  epiphysial 
tuberculosis  the  foci  are  always  near  a  joint,  the  incision  for 
exposing  the  bone  should  be  made  in  such  a  manner  as  to 
avoid  opening  the  joint.  If  the  focus  is  so  close  to  the  joint  as 
to  make  it  necessary  to  remove  bone  underneath  the  insertion 
of  the  capsule  or  ligaments  of  the  joint,  it  is  advisable  to  lift  the 
periosteum  with  the  capsule  from  the  bone  to  some  distance 
from  the  incision,  and  in  this  manner  avoid  injury  to  the  joint. 
The  bone  overlying  a  tubercular  focus  or  abscess  is  usually 
softened  and  easily  removed  with  a  small,  round  chisel.  The  limb 
should  always  be  rendered  bloodless  by  using  Esmarch's  elastic 
constrictor,  so  that  the  operator  can  identify  the  tissues  as  they 
are  being  exposed  and  removed  during  the  operation.  If  after 
tunneling  the  bone  for  a  considerable  distance  the  focus  is  not 
located,  it  is  advisable  to  make  from  this  track  exploratory 


TREATMENT  OF  TUBERCULOSIS  OF  BONE.         125 

punctures  in  different  directions,  with  a  small  perforator,  until 
it  is  found,  when  it  is  freely  exposed  with  the  chisel.  As  soon 
as  this  has  been  done  the  sharp  spoon  is  used,  with  which  the 
necrosed  bone,  granulation  tissue,  or  cheesy  material  is  removed. 
The  osteoporotic  bone  in  the  immediate  vicinity  of  the  cavity  is 
removed  in  a  similar  manner,  and  the  operator  must  assure  him- 
self, by  repeated  examinations  of  the  scrapings  removed,  that 
healthy  tissue  has  been  reached  before  the  sharp  spoon  is  laid 
aside.  If  any  doubt  remain  whether  all  of  the  infected  tissue 
has  been  removed  it  is  better  to  resort  to  ignipuncture,  perforat- 
ing the  bone  at  different  points,  to  the  depth  of  a  few  lines,  with 
the  sharp  point  of  a  Paquelin  cautery  in  addition  to  the 
curetting.  This  procedure  will  destroy  at  least  some  of  the 
bacilli  which  might  have  remained,  and  will  incite  a  plastic 
osteomyelitis,  that  will  effectually  resist  the  pathogenic  action 
of  such  microbes  that  still  remain.  After  the  cavity  has  been 
thoroughly  irrigated  with  iodine  water  it  is  dried,  iodoformized, 
and  packed  with  antiseptic  decalcified  bone-chips.  lodoform  is 
dusted  freely  between  the  chips.  The  periosteum  is  separately 
sutured  over  the  bone-packing,  sufficient  space  being  left  to 
insert  at  the  lower  angle  of  the  wound  a  few  threads  of  catgut 
to  serve  as  a  capillary  drain.  The  remaining  tissues  are  in- 
cluded in  the  superficial  sutures  and  an  antiseptic  dressing 
applied.  The  limb  must  be  immobilized  by  applying  a  well- 
padded,  hollow,  posterior  splint.  The  limb  should  be  kept  in 
an  elevated  position  for  at  least  six  to  twelve  hours.  If  all  the 
infected  tissues  have  been  removed,  and  no  infection  with  pus- 
microbes  has  taken  place  during  or  after  the  operation,  the 
wound  unites  under  one  dressing  in  from  one  to  two  weeks,  and 
the  definitive  healing  of  the  cavity  is  completed  in  the  course  of 
three  to  six  weeks,  according  to  the  condition  and  age  of  the 
patient  and  the  size  of  the  cavity.  The  packing  of  such  cavities 
with  iodoformized,  decalcified  bone-chips  is  an  important  element 
in  the  prevention  of  a  local  recurrence  and  general  infection, 
and  in  securing  satisfactory  healing  of  the  wound  and  complete 


126  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

restoration  of  the  lost  parts.  Should  suppuration  follow  the 
operation,  secondary  implantation  with  decalcified  bone-chips 
can  be  done  successfully  as  soon  as  suppuration  has  ceased,  and 
the  cavity  can  be  made  thoroughly  aseptic.  Excision  of  a  por- 
tion of  the  shaft  of  a  long  bone  is  only  indicated  in  some  cases 
of  diffuse  tubercular  osteomyelitis  below  the  knee-  or  elbow- 
joint  where  amputation  is  considered  unnecessary.  Extirpation 
of  the  entire  bone  affected  is  frequently  called  for  in  tuberculosis 
of  the  wrist,  ankle,  and  tarsus. 

Amputation. — A  mutilating  operation  is  often  the  only 
choice  in  the  treatment  of  diffuse  tubercular  osteomyelitis,  as  it 
offers  the  only  chance  for  complete  eradication  of  the  disease, 
and  protection  of  the  patient  against  general  infection.  It  is 
contra-indicated  in  the  other  forms  of  osteotuberculosis,  unless 
complicated  by  tuberculosis  of  an  adjacent  joint,  and  even  in 
such  instances  it  should  be  limited  to  cases  that  have  passed 
beyond  the  reach  of  a  typical  or  atypical  resection. 


CHAPTER  XIV. 

TUBERCULOSIS  OF  JOINTS. 

Pathology  and  Morbid  Anatomy. — Tuberculosis  of  joints, 
chronic  fungous  arthritis,  strumous  arthritis,  and  tumor  albus 
are  terms  that  even  now  are  being  used  synonymously  to  indi- 
cate a  form  of  inflammation  of  joints  which  is  characterized 
clinically  by  its  chronic  course  and  the  absence  of  acute  signs 
and  symptoms  of  inflammation.  This  affection  is  by  far  the 
most  common  joint  disease  that  comes  under  the  notice  of  the 
surgeon,  so  much  so  that  Konig  states  that  in  surgical  clinics  the 
surgeon  will  have  one  hundred  cases  of  tuberculosis  to  deal  with 
to  one  of  the  other  varieties  of  inflammation,  such  as  gonorrhceal, 
syphilitic,  suppurative,  osteomyelitic,  rheumatic,  or  the  metas- 
tatic  inflammation  following  acute  infectious  diseases.  The  first 
division  of  tubercular  affections  of  joints  upon  an  etiological  and 
pathological  basis  must  be  made  in  reference  to  the  primary 
location  of  the  disease.  The  tubercular  inflammation  occurs 
either  as  a  primary  affection  of  the  synovial  membrane  or  as  a 
secondary  lesion  in  the  course  of  an  epiphysial  bone  tuberculosis. 
The  comparative  frequency  of  these  two  forms  of  joint  tubercu- 
losis has  been  frequently  discussed,  and  even  at  the  present  time 
it  cannot  be  said  that  the  question  has  been  definitely  settled. 
The  specimens  derived  from  early  resections  have  added  largely 
to  our  knowledge  on  this  subject,  but  it  will  require  additional 
research  in  this  direction  before  a  final  decision  can  be  reached. 
Mr.  Price  ("A  Description  of  the  Diseased  Conditions  of  the 
Knee- Joint,"  p.  134.  London,  1865),  from  his  own  experience 
in  the  operative  treatment  of  diseases  of  the  knee-joint,  is  a  firm 
believer  in  the  frequency  of  the  primary  location  of  the  disease 
in  the  articular  ends  of  the  bones,  as  may  be  judged  from  the 
following  language :  "  I  cannot  help  thinking  that  a  large  pro- 
portion of  cases  of  chronic  disease  of  the  joint  consist  in  a 
primary  lesion  of  the  cancellous  structure  of  the  long  bones, 

(127) 


128  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

and  I  am  the  more  inclined  to  this  belief  because,  since  ex- 
cision has  been  frequently  adopted  in  lieu  of  amputation  for 
removal  of  diseased  joints,  greater  opportunities  have  presented 
for  a  closer  and  more  intimate  acquaintance  with  the  exact 
nature  and  origin  of  the  disease."  Other  writers  entertain  an 
opposite  opinion.  Wiseman,  who  did  so  much  to  increase  the 
knowledge  respecting  the  white  swellings  of  joints,  which  he 
was  the  first  to  describe,  recognized — as  we  do  now — the  two 
different  primary  locations  of  the  disease,  as  can  be  seen  from 
the  following  quotation  from  his  writings: — 

"The  swellings  affecting  the  joints  in  this  disease  are  of 
two  sorts.  Both  of  them  are  made  by  congestion  and  increase 
gradually,  yet  different  in  that  the  one  ariseth  externally  upon 
the  tendons  and  between  them  and  the  skin,  or  between  them 
and  the  bone ;  the  other  internally,  within  the  bone  itself.  That 
which  ariseth  externally  affecteth  the  ligaments  and  tendons 
first,  and  sometimes  relaxeth  them  to  such  a  degree  that  the 
heads  of  the  joints  frequently  separate  from  one  another  and  the 
member  emaciates  and  grows  useless ;  but,  for  the  most  part,  the 
tumor,  overmoistening  the  ligaments  and  tendons,  produceth  a 
weakness  and  uneasiness  in  the  joint,  raising  a  tumor  externally, 
and  in  progress  the  membranes  and  bones  are  corroded  by 
reason  of  the  acidity  of  the  humor;  yet  it  is  much  hastened  if, 
upon  a  supposition  of  dislocation,  they  consult  the  bone-setters." 

One  of  the  strongest  pleas  in  regard  to  the  frequency  of 
primary  affection  of  the  synovial  membrane  in  strumous  joint 
disease  we  find  in  the  writings  of  the  distinguished  Cruveilhier 
("Dictionare  de  Medecine  et  de  Chirurgie  pratiques,"  tome  troi- 
sieme,  art.  Articulations).  This  author  expresses  his  opinion  on 
this  subject  as  follows:  "II  est  resultate  de  mon  observation 
que,  dix-neuf  fois  sur  vingt,  ces  maladies  articulaires  ne  sont 
autre  chose  que  des  inflammations  chroniques  des  synoviales; 
que  dix-neuf  fois  sur  vingt  lors  meme  que  tous  les  tissues  fibreux 
et  cellulaires  qui  entourent  une  articulation  ont  ete  ehavis  avec 
la  syiioviale  qui  a  precede  et  qui  domine." 


TUBERCULOSIS   OF   JOINTS.  129 

Benj.  C.  Brodie  ("  Pathological  and  Surgical  Observations 
on  the  Diseases  of  the  Joints."  London,  1850)  described  two 
conditions  of  the  synovial  membrane,  and  cited  illustrative  cases 
of  each  which  now  would  be  considered  as  typical  joint  tubercu- 
losis. In  one  class  "  the  synovial  membrane  had  completely  lost 
its  natural  structure,  being  highly  vascular  and  much  thickened, 
so  that  it  projected  into  the  articular  cavity,  covering  the  margin 
of  the  cartilaginous  surface."  In  another  class,  in  addition  to 
these  changes,  "  vascular  fringes  project  from  it  into  the  cavity  of 
the  joint,  which,  in  a  more  advanced  stage  of  the  disease,  become 
converted  into  a  number  of  membranous  processes  containing  a 
fatty  matter,  and  a  good  deal  resembling,  not  only  in  appearance 
and  in  structure,  the  appendices  epiploicce  of  the  great  intestines." 

Osteo-arthritis. — Primary  tuberculosis  of  the  synovial  mem- 
brane leads  to  osteo-arthritis  after  the  articular  cartilage .  has 
become  destroyed  and  the  tubercular  inflammation  has  attacked 
the  articular  ends  of  the  bone ;  but  this  term  is  used  to  desig- 
nate those  cases  of  joint  tuberculosis  in  which  the  reverse  takes 
place, — primary  osseous  tuberculosis  followed  by  tubercular 
inflammation  of  the  joint.  It  is  important  to  know  how  many 
cases  of  primary  bone  tuberculosis  are  followed  by  joint  com- 
plications. Konig's  operative  experience  has  shown  that  a 
single  focus  near  a  joint  can  give  rise  to  joint  tuberculosis,  and 
this  is  especially  the  case  if  the  inflammatory  area  is  large.  In 
some  cases  of  bone  tuberculosis  multiple  foci  are  present  at  the 
same  time,  or  form  in  rapid  succession  ;  thus,  in  caries  sicca  the 
foci  are  numerous,  and  give  rise  to  extensive  local  defects. 
Granulating  foci  are  more  likely  to  occur  as  a  multiple  affection 
than  the  sequestrating  form  of  bone  tuberculosis.  A  combina- 
tion of  these  two  forms  is  of  rather  frequent  occurrence.  Among 
one  hundred  and  fifty-four  specimens  from  the  hip,  knee,  and 
elbow  examined  by  Konig,  in  ninety-five  only  one  focus  was 
found,  while  the  remaining  showed  two  or  more.  In  this  respect 
a  difference  is  seen  in  the  different  joint  specimens,  as  in  the 
knee  the  number  of  single  foci  was  twice  as  great  as  the  multiple 


130  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

lesions.  In  the  hip-joint  the  number  of  each  is  about  the  same, 
while  in  the  elbow  only  one-third  of  the  cases  presented  multiple 
lesions. 

The  danger  of  extension  of  a  primary  osseous  focus  into  a 
joint  depends  on  the  primary  location  of  the  disease.  The 
nearer  the  osseous  lesion  is  to  the  joint  the  greater  the  proba- 
bility that  it  will  extend  in  that  direction  and  invade  the  joint. 

After  perforation  into  the  joint  has  occurred,  the  tubercu- 


Fio.  21.— COMMON  FORM  OF  OSTEOTUBERCULOSIS  OF  ELBOW-JOINT.    (Volkmann.) 

Patient,  a  girl  eight  years  old.  Fistnlous  opening  over  olecranon  process.  Perforation  Into  joint, 
which  is  the  seat  of  a  fungous  inflammation.  Fistulous  opening  enlarged,  sequestrum  removed  ;  joint 
incised  and  drained  over  head  of  radius  ;  recovery,  with  perfect  use  of  joint. 

lar  material,  as  a  rule,  is  brought  in  contact  with  the  entire 
joint  surfaces,  and  causes  a  diffuse  tubercular  synovitis.  It 
sometimes  happens  that,  by  a  coincidence  of  a  number  of  favor- 
able circumstances,  general  infection  of  the  joint  is  prevented. 

Such  specimens  bear  evidence  that  invasion  of  the  whole 
joint  was  rendered  impossible  by  a  plastic  inflammation  of  the 
soft  structures  of  the  joint  where  perforation  was  about  to  take 
place,  which  resulted  in  isolation  of  the  extravasated  tubercular 
material  and  protection  of  the  remaining  portion  of  the  cavity 


TUBERCULOSIS   OF   JOINTS. 


131 


of  the  joint  by  an  impermeable  wall  of  connective  tissue.  Such 
a  favorable  occurrence  is  most  frequently  observed  in  the  knee- 
joint  of  children.  More  frequently,  however,  perforation  into 
the  joint  is  the  cause  of  a  speedy  infection  of  the  entire  syno- 
vial  surface.  The  tubercular  synovitis  is  always  most  marked 
in  recent  cases  around  the  perforation,  and  the  process  extends 
from  here  in  all  directions.  Secondary  tubercular  synovitis 


FIG.  22.— TYPICAL  GRANULATION  TUBERCULOSIS  OF  SYNOVIAL  MEM- 
BRANE WITH  MANY  ROUND  AND  OBLONG  TUBERCLES,  AND  BETWEEN  THEM 
STRIPES  OF  TUBERCULAR  INFILTRATION.  (Konig.) 

appears  in  all  forms  which  characterize  the  primary  disease  of 
this  structure.  Part  of  the  granulations  in  a  tubercular  *joint 
are  not  infected,  but  are  the  product  of  a  plastic  inflammation. 
Granulation  tissue  of  this  kind  is  often  found  underneath  the 
articular  cartilage,  which  it  separates  from  the  bone.  The  car- 
tilage often  presents  a  cribriform  appearance,  from  the  numer- 
ous small  perforations  made  by  the  granulations  upon  and 


132  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

underneath  it.  The  behavior  of  the  parasynovial  tissue  is 
characteristic.  (Edematous  infiltration  is  especially  well  marked 
in  places  where  the  subsynovial  fat  is  abundant.  The  atrophic 
fat  becomes  cedematous  from  serous  trail sudation.  The  tubercu- 
lar granulations  of  the  synovial  membrane  are  friable,  and  show 
evidences  of  caseation.  The  granulations  springing  from  the 
articular  surfaces  of  the  bones  often  present  appearances  of  a 
tubercular  nature  as  much  as  those  in  the  synovial  membrane. 
The  tubercle-nodules  are  very  numerous,  imparting  to  the  gran- 
ulations a  follicular  structure.  The  ground-substance  in  which 
the  nodules  are  imbedded  is  variable.  Tubercles  which  mani- 
fest a  tendency  to  rapid  disintegration  are  imbedded  in  soft 
granulations  infiltrated  with  round-cells,  in  which,  besides  the 
tubercles,  isolated  giant-cells  are  to  be  found.  Konig  describes 
in  the  tubercular  synovial  membrane,  besides  the  common 
tubercle,  a  variety  peculiar  to  this  location. 

Through  the  granulations  traverse  narrow,  communicat- 
ing streaks  of  epithelioid  cells,  giving  an  appearance  as  though 
the  infiltration  had  taken  place  in  pre-existing  connective-tissue 
spaces.  Often  the  impression  gains  ground  as  though  the  infil- 
tration had  occurred  in  the  course  of  blood-vessels.  Besides 
these  granulations,  tubercle-nodules  are  also  found  in  the 
inflamed  tissues,  especially  the  connective-tissue  spaces. 

Primary  Synovial  Tuberculosis. — In  synovial  tuberculosis 
a  series  of  pathological  changes  are  initiated,  in  which  all  the 
structures  of  the  joint  are  finally  concerned,  namely,  the  synovial 
membrane,  parasynovial  tissues,  articular  cartilage,  and,  lastly, 
the  bone.  The  tubercle-nodule  in  the  synovial  membrane  pre- 
sents, under  the  microscope,  the  same  histological  structure  as 
in  other  tissues.  When  the  synovial  membrane  has  become  the 
seat  of  diffuse  tuberculosis,  the  tissues  undergo  the  same  patho- 
logical changes  as  during  the  first  stage  of  tuberculosis  in  other 
organs,  and  it  is  the  characteristic  granulation  tissue  that  has 
given  this  form  of  arthritis  the  names  of  fungous  arthritis,  fungous 
synovitis,  and  synovitis  Jiyperplastica  granulosa.  (Hueter.) 


TUBERCULOSIS   OF   JOINTS.  133 

The  tubercular  nature  of  this  form  of  synovitis  was  firmly 
established  by  Koster  ("  Ueber  fungose  Gelenkentziindung." 
Virchow's  Archiv,  B.  xlviii,  p.  95),  who  showed,  as  early  as  1869, 
that  numerous  miliary  tubercles  are  regularly  found  imbedded 
in  the  granulations  in  every  case  of  fungous  synovitis,  and  that 
they  can  also  be  found  with  the  same  constancy  in  the  walls 
lining  fistulous  tracts  and  in  the  membrane  upon  the  wall  of 
chronic  abscesses.  In  the  fungous  synovial  membrane  he  found 
them  near  the  surface  of  the  granulations,  in  a  single  layer,  in 
the  vascular  and  swollen  tissues  of  the  synovial  membrane,  or 
in  the  coverings  of  the  articular  fat.  He  showed,  further,  that, 
histologically,  the  nodules  in  the  granulations  are  identical  with 
the  ordinary  tubercle.  He  called  attention  to  the  fact  that  they 
undergo  caseation.  The  nodules  are  arranged  in  groups,  often 
so  dense  that  they  represent  a  glandular  structure.  In  the 
deeper  portions  of  the  synovial  membrane  they  become  less 
numerous.  The  groups  are  usually  supplied  with  a  single 
vessel,  of  considerable  size,  which  forms  a  net-work  of  capillary 
vessels  around  them.  The  periphery  of  the  nodules  is  com- 
posed of  lymphoid  cells,  which  become  larger  and  richer  in 
protoplasm  toward  the  centre.  He  found  in  the  centre  of  each 
nodule  one  or  more  giant-cells.  He  even  gave  a  minute  descrip- 
tion of  the  anastomotic  projections  of  these  cells.  In  nine  cases 
of  fungous  synovitis  the  autopsy  revealed  no  tubercle  in  any 
other  organ,  with  the  exception  of  one  in  which  tubercular 
cavities  were  found  in  the  apex  of  one  of  the  lungs.  The  author 
reminds  the  reader  that  in  the  miliary  form  of  tuberculosis 
caseation  of  the  nodules  takes  place  more  speedily  than  in  the 
synovial  membrane. 

Konig  ("  Die  Tuberculose  der  Gelenke."  Deutsctie  Zeits- 
chrift  /.  Chirnrgie,  B.  xi,  p.  531)  examined  seventy-two  dis- 
eased joints,  and  found  in  sixty-seven  of  them  the  character- 
istic appearances  of  tuberculosis.  He  found  giant-cells  so  con- 
stantly that  he  asserts  if  they  cannot  be  seen  they  are  not  found. 
Besides,  in  the  granulation  tissue  he  found  tubercles  in  the 


134  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

fibrous  portion  of  the  synovial  membrane  and  in  the  fatty  ap- 
pendages of  tubercular  joints.  The  number  of  tubercles  in 
different  parts  of  the  joint  varies ;  they  are  found  with  the 
greatest  certainty  in  the  osseous  foci,  which  are  often  composed 
of  them  entirely ;  at  other  times,  the  whole  synovial  membrane 
is  permeated  by  nodules.  In  the  peripheral  portion  of  the 
articular  cartilage  they  often  appear  in  circumscribed  tuberous 
form.  In  seventy-one  cases  of  tuberculosis  of  joints  he  found 
the  primary  disease  in  bone  forty-seven  times.  These  early 
publications  on  the  tubercular  nature  of  most  of  the  chronic 
affections  of  joints  led  other  surgeons  to  make  inquiries  in 
the  same  direction,  and  confirmatory  evidence  of  the  opinion 
of  these  authors  accumulated'  rapidly.  During  the  early  stage 
of  the  disease  the  surgeon  meets  with  two  distinct  varieties ;  in 
one,  the  tubercular  infection  produces  a  pulpy  condition  of  the 
entire  synovial  sac,  with  little  or  no  effusion  into  the  joint,  the 
swelling  being  entirely  due  to  the  presence  of  a  thick  layer  of 
granulation  tissue, — the  true  tumor  albus  of  the  old  writers. 
This  form  of  tuberculosis  gives  rise,  at  an  early  stage,  to  exten- 
sive deformity  of  the  joint,  flexion,  rotation,  and,  in  the  case 
of  the  knee-joint,  partial  dislocation  of  the  tibia  backward.  In 
the  other  variety  the  fungous  granulations  are  scanty,  but  a 
copious  effusion  takes  place  into  the  joint,  giving  rise  to  tuber- 
cular liydrops,  which  simulates  a  catarrhal  synovitis,  until  time 
and  the  effect  of  treatment  enable  the  surgeon  to  make  a  correct 
differential  diagnosis.  In  this  form,  Konig  assures  us  that  he 
has  never  observed  a  tendency  to  flexion  or  any  other  form  of 
displacement  of  the  joint-surfaces.  If  suppuration  take  place, 
which  is  not  often  the  case,  it  begins  in  the  granulations  which 
cover  the  synovial  membrane,  and  the  pus  accumulates  in  the 
cavity  of  the  joint,  causing  an  articular  empyema,  until  per- 
foration of  the  capsule  takes  place.  During  the  suppurative 
process  the  granulations  are  destroyed,  and  the  tubercular 
infection  penetrates  deeper,  and,  as  during  the  destructive 
process  blood-vessels  are  destroyed,  the  patient  is  exposed  to  the 


TUBERCULOSIS  OF  JOINTS.  135 

additional  risks  of  general  infection.  If  a.  tubercular  joint 
open  spontaneously,  or  is  incised  without  observing  strict  anti- 
septic precautions,  the  additional  infection  from  without  leads 
to  the  most  serious  consequences,  as,  under  these  circumstances, 
pus-microbes  are  brought  in  contact  with  a  surface  that  has 
been  admirably  prepared  by  the  bacillus  of  tuberculosis  for 
strppurative  and  septic  processes. 

Anatoinico- Pathological  Varieties  of  Joint  Tuberculosis. — 
The  classification  of  tubercular  affections  of  the  joints  on  an 
anatomico-pathological  basis  is  made  in  reference  to  the  char- 
acter of  the  inflammatory  product.  This  varies  according  to  the 
extent  and  intensity  of  the  disease  and  the  stage  of  the  retrograde 
degenerative  changes.  The  histological  structure  of  the  tuber- 
cular product,  as  revealed  under  the  microscope,  is  the  same 
during  the  early  stage  of  tubercular  synovitis,  but  the  abundance 
of  new  tissue  and  the  differences  observed  in  the  rapidity  with 
which  the  inflammatory  material  undergoes  coagulation  necrosis, 
caseation,  and  liquefaction  of  the  cheesy  material  in  different 
cases  are  conditions  which  characterize  the  different  pathological 
varieties  which  will  now  be  enumerated  and  described. 

Classification  upon  such  a  basis  is  of  great  practical  im- 
portance, as  upon  it  depends  the  adoption  of  appropriate  treat- 
ment in  any  given  case.  For  instance,  a  tubercular  synovitis 
without  caseation  would  indicate  expectant  treatment  by  rest 
and  the  use  of  intra-articular  injections,  and  if  this  treatment 
fail  an  arthrectomy  would  in  all  probability  yield  a  favorable 
result.  On  the  other  hand,  if  the  synovial  tuberculosis  has  de- 
stroyed the  articular  cartilage,  and  has  involved  the  articular 
extremities  of  the  bones,  the  prospects  of  recovery  under  ex- 
pectant treatment  are  reduced  to  a  minimum,  and  if  operative 
interference  is  decided  upon  an  atypical  or  typical  resection 
becomes  an  unavoidable  necessity. 

Acute  Miliary  Tuberculosis  of  the  Synovial  Membrane. — 
Konig  describes  a  form  of  tuberculosis  of  the  synovial  mem- 
brane in  which  miliary  tubercles  are  found  in  the  subsynovial 


136  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

tissue,  and  in  which  the  synovial  membrane  is  not  at  all  altered. 
There  are  no  symptoms  of  disease  of  the  joint.  This  condition 
occurs  in  acute  general  tuberculosis,  and  is  lilte  the  same  affec- 
tion in  bone,  only  of  pathological  interest.  A  correct  diagnosis 
is  only  possible  in  the  post-mortem  room.  Primary,  diffuse 
miliary  tuberculosis  may  present  itself  with  or  without  an 
osseous  focus ;  if  the  latter  is  present  it  does,  however,  not  com- 
municate with  the  joint,  and  occurs  simultaneously  with  the 
joint  affection.  The  local  conditions  are  variable.  In  one  form 
small  gray  tubercles  are  scattered  through  the  deeper  layers  of 
the  synovial  membrane,  while  its  surface  has  undergone  little  or 
no  alteration  and  the  joint  remains  useful,  and  the  patient 
makes  no  complaint  and  presents  no  other  indications  of  the 
existence  of  the  joint-lesion.  In  other  instances  granulations  do 
not  form,  and  the  only  evidence  that  points  to  the  existence  of 
the  tubercular  joint  affection  is  a  slight  hydrops  of  the  joint. 

Tubercular  Hi/drops. — A  tubercular  affection  of  the  syno- 
vial membrane  giving  rise  to  a  copious  effusion  into  the  joint 
is  called  tubercular  hy drops.  Pathologically  this  form  of  joint 
tuberculosis  bears  a  strong  resemblance  to  tubercular  ascites. 
Macroscopically  the  synovial  membrane  presents  but  slight 
alteration,  as  the  tubercle-nodules  are  few  and  imbedded  in  the 
synovial  membrane.  Within  a  short  time  the  joint  becomes 
distended  with  fluid,  but  pain  is  slight  or  altogether  absent,  and 
the  patient  is  able  to  use  the  limb.  The  fluid  withdrawn  by 
tapping  or  aspiration  resembles  the  normal  synovial  secretion ; 
sometimes  it  is  less  viscid  and  contains  small  shreds  of  lymph, 
which  have  become  detached  from  the  surface  of  the  membrane. 
After  removal  of  the  fluid  the  normal  size  and  contour  of  the 
joint  are  restored.  Re-accumulation,  as  a  rule,  takes  place 
rapidly,  and  after  a  few  days  the  effusion  is  as  copious  as  before 
the  tapping.  In  other  cases  the  fibrinous  deposits  are  more 
abundant;  then  we  speak  of  a  hydrops  fibrinosus.  It  seems 
that  during  the  early  stages  of  this  variety  of  joint  tuberculosis 
the  inflammation  disturbs  the  equilibrium  between  secretion 


TUBERCULOSIS   OF   JOINTS.  137 

and  absorption  of  the  synovial  fluid,  which  is  in  all  probability 
accomplished  by  a  specific  form  of  alteration  of  the  vessel- walls, 
permitting  free  transudation,  while  at  the  same  time  the  absorp- 
tive capacity  of  the  joint  is  impaired.  Thickening  of  the  syno- 
vial membrane  takes  place  later,  and  ultimately  the  joint  pre- 
sents the  characteristic  appearances  of  tubercular  synovitis.  A 
correct  diagnosis  in  these  cases  is  often  only  possible  by  the 
subsequent  clinical  course  of  the  disease. 

A  painless,  rapidly-forming  mono  articular  liydrops  is 
always  a  suspicious  affection,  and,  if  the  case  prove  rebellious 
to  ordinary  treatment,  a  suspicion  of  its  tubercular  nature  should 
always  be  entertained,  and  this  suspicion  always  becomes  well 
grounded  if,  after  the  hydrops  has  disappeared  spontaneously 
or  under  appropriate  treatment,  the  joint  remains  swollen  and 
presents  other  indications  of  the  tubercular  character  of  the  in- 
flammatory product.  For  the  remaining  forms  of  tubercular 
synovitis  Hueter's  (KUniJc  der  Gelenlckranlcheiten,  Leipzig, 
1876)  classification  still  remains  as  the  best. 

Synovitis  Hyperplastica  Lcevis  S.  Pannosa. — In  this  form 
the  synovial  membrane  is  only  slightly  thickened  and  vas- 
cular, and  its  surface  remains  smooth.  The  tubercle-nodules 
are  extremely  small,  rarely  visible  to  the  naked  eye,  and  widely 
disseminated  over  the  entire  or  'greater  portion  of  the  synovial 
sac.  Under  the  microscope  the  intima  is  seen  to  be  composed 
of  several  layers  of  cells,  and  between  them  exists  a  well-marked 
system  of  juice-canals.  The  synovial  membrane  is  not  only 
thickened,  but  its  surface  at  the  same  time  is  greatly  increased 
at  the  expense  of  the  articular  surfaces.  From  the  border  of  the 
cartilage  a  thin,  vascular  layer  of  granulations  approaches  the 
centre  of  the  surface  of  the  joint  somewhat  in  the  manner  a 
pannus  invades  the  cornea.  Those  parts  of  the  articular  sur- 
faces which,  in  the  embryo,  are  covered  by  a  physiological 
pannus  are  first  the  seat  of  this  pathological  process,  which 
resembles  the  former  macroscopically  and  microscopically. 

Synovitis  Hyperplastica  Granulosa. — This  variety  appears 


138  TTJBE&CULOSIS   OP   THE   BdNES   AND   JOINTS. 

to  be  only  a  more  advanced  stage  of  the  preceding.  They  fur- 
ther resemble  each  other  in  that  hydrops  does  not  occur  in 
either  of  them.  In  this  form  of  joint  tuberculosis  the  synovial 
membrane  is  affected  throughout,  being  considerably  thickened 
and  hyperaemic,  and  covered  by  a  more  or  less  thick  layer  of 
velvety  granulations.  The  abundance  of  granulation  tissue 
which  is  always  present  in  this  type  of  synovitis  induced  Bill- 
roth  to  apply  the  term  fungous  synovitis.  The  granulations  are 
produced  by  proliferation  from  the  intima  of  the  synovial  mem- 
brane. The  granulations  resemble  somewhat  the  granulations 
of  an  open  wound,  but  differ  from  them  by  being  less  vascular. 
The  synovial  granulations  are  pathological  products,  and  do  not 
tend  to  undergo  cicatrization.  The  tubercle  bacilli  imbedded 
in  the  granulations  retard  the  growth  of  young  blood-vessels, 
and  in  this  manner  determine  early  degenerative  changes  of  the 
inflammatory  product.  The  ligaments  and  para-articular  struc- 
tures are  affected  at  a  comparatively  early  stage,  and  thus  is 
formed  the  thick,  cedematous  mass  of  tissue,  usually  of  a  gela- 
tinous appearance,  in  which,  here  and  there,  cheesy  foci  are 
found.  In  the  beginning  of  the  disease  a  microscopical 
examination  of  sections  of  the  synovial  membrane  will  show 
that  this  structure  is  divided  into  two  parts, — an  internal  layer, 
where  the  tissue  is  soft  and,  at  an  early  stage,  villous,  and  later 
covered  with  caseous  material,  and  an  external  or  firmer  layer, 
without  caseation.  The  soft  layer  does  not  always  cover  the 
whole  surface,  and  can  be  frequently  rubbed  off,  with  very 
slight  pressure.  The  relative  thickness  of  these  two  layers 
varies  greatly  in  different  specimens.  In  a  second  type  no  such 
distinction  in  layers  can  be  made,  the  synovial  membrane  being 
composed  essentially  of  the  firmer  tissue,  but  the  surface  is 
infiltrated  with  tubercle-nodules  in  various  stages  of  degenera- 
tion. In  a  third  variety  of  cases  there  is  much  thickening  of 
the  synovial  membrane  and  subsynovial  tissues,  which  often 
appear  cedematous,  and  the  tubercles,  if  present,  are  usually 
limited  to  the  vicinity  of  osseous  foci.  In  this  variety  of  syno- 


TUBERCULOSIS   OF   JOINTS.  139 

vial  tuberculosis  infection  takes  place  on  the  surface,  and 
extends  from  here  to  the  deeper  tissues;  while  caseation  is 
taking  place  on  the  surface  of  the  membrane  the  process  extends 
into  the  substance  of  the  membrane  and  the  tissues  outside  of 
it.  In  advanced  cases  the  two  layers  of.  the  synovial  membrane 
are  no  longer  distinguishable,  as  the  degenerative  changes  have 
brought  about  coalescence.  In  another  variety,  as  in  simple 
hyperplastic  synovitis,  tubercles  are  not  deposited  primarily  on 
the  surface  of  the  synovial  membrane,  but  in  its  substance  and 
underneath  it.  During  the  progress  of  the  disease  the  whole 
thickness  of  the  membrane  becomes  involved,  and  after  this  has 
occurred  the  condition  resembles  the  cases  in  which  primary 
localization  occurred  upon  the  surface  of  the  intima.  In  such 
cases  caseation  takes  place  later,  and  the  formation  of  abscesses 
is  of  less  frequent  occurrence.  In  the  third  type  of  diffuse 
synovial  tuberculosis  the  tubercles,  which  are  few  in  number, 
are  deposited  in  the  fibrous  portion  of  the  synovial  membrane. 
In  some  places  the  membrane  is  much  thickened,  but  contains 
no  tubercles,  the  swelling  being  due  to  the  presence  of  an 
exudation  resulting  from  a  plastic  inflammation  caused  by  and 
accompanying  the  tubercular  process.  This  form  may  originate 
as  a  primary  synovial  tuberculosis,  but  more  frequently  it  follows 
in  connection  with  osseous  foci  which  have  not  yet  reached  the 
surface.  It  is  important  to  determine  the  extent  of  the  disease 
in  the  operative  treatment  of  joint  tuberculosis,  as  it  is  now 
generally  conceded  that  operations  should  be  limited  to  the 
removal  of  diseased  tissues.  If  infection  has  not  extended 
beyond  the  limits  of  the  synovial  membrane  an  arthrectomy  is 
indicated ;  but  if  the  disease  has  reached  the  structures  outside 
of  it,  an  atypical  or  typical  resection  is  indicated. 

Synovitis  Hyperplastica  Tuberosa. — This  is  a  compara- 
tively rare  form  of  joint  tuberculosis,  and  a  positive  anatomical 
diagnosis  is  usually  a  post-operative  or  post-mortem  revelation. 
This  affection  of  the  synovial  membrane  was  first  described  by 
Biedel  and  Konig.  The  tubercular  inflammation  results  in  the 


140 


TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 


formation  of  circumscribed,  subsynovial  masses,  which  may 
attain  the  size  of  a  walnut,  projecting  into  the  joint  and  filling, 
for  instance,  the  supra-patellar  recess  of  the  knee-joint.  The 


FIG.  24.    (Natural  size.)  FIG.  25.    (Natural  size.) 

SECONDARY  TUBERCULOSIS  OF  KNEE-JOINT.  GREAT  HYPERTROPHY  OF 
SYNOVIAL  AND  SUBSYNOVIAL,  TISSUES.    (Jfrause.) 

All  three  specimens  removed  from  the  same  joint.    lu  Fig.  25  the  tubercle-nodules  can  be  distinctly  seen. 

disease  is  attended  by  simple  irritative  synovitis  or  pannous 
synovitis  in  the  rest  of  the  synovial  membrane.  In  the  typical 
form  of  tuberous  synovitis  the  infection  is  limited,  and  the 
operative  removal  of  the  fibrous  swelling  or  swellings  results  in 


TUBERCULOSIS   OF   JOINTS.  141 

a  permanent  cure.  In  other  cases  the  affection  is  more  diffuse, 
the  foci  of  infection  and  hyperplastic  inflammation  numerous, 
giving  rise  to  papillomatous  plastic  synovitis,  where  the  whole 
inner  surface  of  the  synovia!  membrane  is  covered  with  sessile 
or  pedunculated  papillomatous  growths,  small  and  rather  uni- 
form in  size,  some  of  which  may  become  detached,  when  they 
constitute  the  so-called  rice-bodies.  This  condition  of  a  joint 
lias  also  been  described  as  lipoina  arborescens  tuberculosum. 
Clinically  it  is  a  form  of  joint  tuberculosis  in  which  the 
pathological  product  appears  as  a  firm  swelling,  with  little 
tendency  to  softening  and  caseation.  It  is  found  most  frequently 
in  the  knee-joint,  and  occasionally,  also,  on  tendons  and  in 
tendon-sheaths.  Riedel  describes  the  characters  of  these  cases 
as  follows :  "  The  synovial  membrane  is  reddened,  often  thick- 
ened, and  shows  one  or  more  firm  prominences  on  the  surface ; 
the  joint  frequently  contains  fluid  and  rice-like  bodies ;  the 
nodules  contain  numerous  tubercles,  often  closely  packed 
together."  The  anatomical  structure  of  the  inflammatory 
product  is  variable.  Frequently  it  is  found  as  a  single  swelling, 
the  size  of  a  hazel-nut,  more  or  less  flattened,  and  develops 
from  the  fibrous  portion  of  the  synovial  membrane.  The  struc- 
ture is  firm,  of  a  grayish-red  color,  infiltrated  with  light-gray 
nodules,  the  size  of  a  pin's  head.  The  swelling  is  completely 
covered  by  the  intact  intima.  Microscopically  the  bulk  of  the 
mass  is  composed  of  young  connective  tissue,  partly  in  a  state 
of  fatty  degeneration,  bounded  by  a  layer  of  firm  connective 
tissue.  The  defective  blood-supply  leads  to  early  degenerative 
changes.  In  the  deeper  portions  of  the  swelling  remnants  of 
tubercles  are  found,  while  in  the  vascular  portion  tubercles  are 
numerous.  In  some  places  numerous  degenerated  blood-vessels 
can  be  found.  These  vessels  have  thickened  walls,  and  the 
capillary  vessels  are  surrounded  by  many  layers  of  spindle- 
shaped  cells.  In  the  inflamed  tissues  between  the  vessels 
tubercle-nodules  are  always  present.  In  some  specimens  por- 
tions of  the  swelling  present  an  angiomatous  appearance,  the 


142  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

vessels  being  very  numerous  and  the  cellular  elements  scanty. 
In  this  form  of  joint  tuberculosis  there  is  always  a  tendency  to 
deposition  of  fibrinous  masses  in  the  interior  of  the  joint. 
When  this  occurs  the  synovial  membrane  becomes  thickened 
over  the  tubercular  product,  which  always  increases  the  size  of 
the  swelling.  In  some  specimens  the  whole  surface  of  the 
synovial  membrane  is  covered  with  papillomatous  formations. 
The  tuberous  form  of  synovial  tuberculosis  is  always  a  local 
infection.  The  inflammatory  product  in  the  interior  of  which 
the  tubercles  are  located  is  the  result  of  a  local  disease. 

Tubercular  Empyema  of  Joints. — The  pathological  condi- 
tion of  tubercular  joints  for  which  Konig  proposes  the  name 
synovitis  suppurativa  tubercidosa  is  comparatively  rare.  Tuber- 
cular pyarthrosis  of  joints  is  observed  in  different  anatomical 
forms.  The  most  typical  form  which  corresponds  very  closely  to 
the  cold  abscess  of  the  old  authors  is  the  one  in  which  the  syno- 
vial membrane  is  attacked  with  diffuse  tuberculosis  without  the 
production  of  copious  granulations.  Less  characteristic  are  the 
cases  in  which  the  same  condition  is  established  in  joints  which 
contain  a  thick  layer  of  granulation  tissue.  The  first  form  is 
met  with  most  frequently  in  the  knee-joint  of  children,  less  fre- 
quently in  the  hip-joint.  In  children  the  abscess  develops  often 
very  rapidly,  resembling  in  its  clinical  history  hydrops  or  acute 
suppurative  synovitis.  It  attends  most  frequently  primary 
diffuse  synovial  tuberculosis,  and  is  less  frequently  associated 
with  secondary  infection  of  a  joint  from  an  osseous  focus.  The 
tubercular  abscess  of  joints  is  an  advanced  stage  of  the  other 
varieties  of  tubercular  synovitis.  The  tendency  to  caseation 
and  liquefaction  of  the  cheesy  material  varies  greatly  in  the 
different  forms  of  joint  tuberculosis.  As  a  rule,  these  retro- 
grade degenerative  changes  are  slow  to  appear  in  cases  in  which 
the  tubercular  inflammation  results  in  the  production  of  an 
abundance  of  granulation  tissue,  and  they  are  most  prone  to 
occur  in  cases  of  diffuse  tuberculosis  of  the  synovial  membrane 
attended  by  scanty  proliferation  of  tissue.  In  the  typical  tuber- 


TUBERCULOSIS   OF   JOINTS. 


143 


cular  empyema  of  joints  the  synovial  membrane  and  capsule 
are  not  much  thickened,  and  offer  but  little  resistance  to  the 
intra-articular  pressure ;  the  joint  is,  therefore,  often  enor- 
mously swollen,  and  the  capsule  greatly  distended.  The  inside 
of  the  capsule  is  covered  with  a  loosely-adherent  tubercular 
membrane,  similar  to  that  in  tubercular  abscesses.  The  super- 
ficial granulations  which  compose  this  membrane  have  under- 
gone degenerative  changes.  Outside  of  this  membrane  the 


FIG.  26.— RESECTED  UPPER  END  OF  FEMTJR.    ( Volkmann.) 

Tubercular  foci  immediately  under  the  articular  cartilage,  which  is  separated,  hood-like,  from  the  bone  by 
the  suppuration,    a,  cribriform  perforatious  of  the  cartilage. 

tissues  are  diffusely  infiltrated  with  miliary  tubercles,  but  the 
infection  does  not  extend  beyond  the  synovial  membrane.  The 
fluid  in  the  joint,  like  in  all  tubercular  abscesses,  is  not  pus, 
but  serum,  in  which  we  find  suspended  the  products  of  coagu- 
lation necrosis.  With  the  extension  of  the  tubercular  process 
beyond  the  limits  of  the  synovial  sac,  the  articular  cartilage 
and,  finally,  the  bone  are  successively  attacked.  The  articular 
cartilage  takes  no  active  part  in  the  inflammatory  process, — it 
is  detached  and  removed  by  the  granulations.  An  osseous 


144  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

focus  in  contact  with  the  cartilage  usually  makes  a  circular 
defect  through  which  the  granulations  or  cheesy  material  can 
be  seen.  The  cartilage  covering  a  tubercular  infarct  is  rapidly 
destroyed,  and  is  mechanically  detached  in  smaller  or  larger 
fragments.  In  primary  tuberculosis  of  the  synovia!  membrane 
the  process  usually  commences  at  the  periphery  of  the  articular 
cartilage,  and  from  here  the  granulations  dip  down  into  the 
vascular  bone,  and  often  undermine  the  cartilage  extensively 
before  any  destructive  changes  are  witnessed  on  the  side  directed 
toward  the  joint.  In  such  cases  the  cartilage  is  not  only  exten- 
sively detached,  but  perforated  at  numerous  points  by  the  gran- 
ulations underneath  it.  The  action  of  the  granulations  on  the 
articular  extremities  of  the  bone  produces  a  condition  which 
has  been  described  for  centuries  as  caries.  Caries  is  not  a  dis- 
ease, but  the  result  of  a  disease.  The  bone  becomes  softened, 
and  by  molecular  disintegration,  caused  by  the  action  of  the 
granulations,  it  becomes  porous  and  honey-combed. 

Numerous  miliary  nodules  can  be  seen  in  the  affected  area 
which,  in  the  course  of  time,  undergo  coagulation  necrosis  and 
caseation.  In  long-standing  cases  the  destruction  of  bone  is  so 
extensive  that  in  the  hip-joint,  for  instance,  it  may  result  in  the 
loss  of  the  entire  head  of  the  femur  and  perforation  of  the  ace- 
tabulum.  The  fluid  in  abscess  of  a  joint  is  an  emulsion  com- 
posed of  liquefied  cheesy  material,  fragments  of  degenerated 
tissue  and  detached  particles  of  cartilage  and  bone  if  the  tuber- 
cular process  has  involved  these  structures.  The  joint-abscess, 
under  favorable  local  and  general  conditions,  sometimes  devel- 
ops speedily  and  early ;  at  other  times  it  appears  slowly,  and 
months  and  often  years  after  the  inception  of  the  primary 
disease. 


CHAPTER  XV. 

SPECIAL  POINTS  IN  THE  PATHOLOGY  OF  SYNOVIAL  TUBERCULOSIS. 

Rice-Bodies. — Loose  bodies  in  the  joint,  the  so-called  rice- 
bodies,  are  now  known  to  be  of  a  tubercular  nature,  resulting 
from  a  formation  of  new  tissue  usually  on  the  surface  of  the 
synovial  membrane.  The  larger  corpora  mobilia  have,  as  a 
rule,  a  traumatic  origin.  If  the  trauma  has  not  split  off  com- 
pletely a  portion  of  the  articular  surface,  an  occurrence  which 
Schuchardt  thoroughly  described,  cartilage  or  cartilage  and  bone, 
it  results  in  inflammatory  changes  which  later  accomplish  the 
separation.  Klein  (Virchow's  Archiv,  B.  xxix,  p.  190)  has 
called  this  latter  process  "spontaneous  demarcation";  Krage- 
lund  (Centrcdbhttt  f.  Chinirgie,  1887,  p.  412),  "ostitis";  Broca, 
"necrosis  of  cartilage" ;  and  Konig,  "osteochondritis  dessicans." 
That  the  process  is  not  of  a  necrotic  nature  is  evident  from  the 
fact  that  some  of  the  loose  bodies  show  evidences  of  proliferation, 
and  sometimes  increase  in  size  after  their  detachment,  the  nour- 
ishment being  furnished  by  the  synovial  fluid. 

The  minute  structure  and  tubercular  nature  of  the  so-called 
rice-bodies,  corpora  oryzoidea,  so  frequently  present  in  tubercu- 
lar joints  and  tendon-sheaths,  were  first  accurately  described 
and  pointed  out  by  Riedel  ("Zur  vEtiologie  der  fibrinosen  Fremd- 
korper  im  Knie."  Deutsclie  Zeitschrift  f.  Cliirurgie,  B.  x). 
These  bodies  vary  in  size  from  a  cucumber-seed  to  a  melon-seed, 
and  in  color  and  consistence  resemble  the  grains  of  boiled  rice. 
Their  presence  in  a  joint  or  tendon-sheath  is  almost  a  sure  in- 
dication of  the  tubercular  nature  of  the  disease  of  these  struc- 
tures which  produce  them.  According  to  Konig  ("  Die  Bedeu- 
tung  des  Faserstoffes  fuer  die  pathologische  Anatomic  und  die 
Entwickelung  der  Gelenk  und  Sehnenscheiden  tuberculose." 
Cfntralblatt  f.  CJu'rurgie,  B.  xiii,  No.  25),  these  bodies  are  com- 
posed almost  exclusively  of  fibrin.  He  believes  that  fibrinous 
exudation  is  one  of  the  constant  products  of  tubercular  inflam- 

10  (145) 


146 


TUBERCULOSIS    OF   THE    BONES    AND    JOINTS. 


mation  of  joints  and  tendon-sheaths,  and  that  these  bodies  are 
fibrinous  concrements  varying  in  size  and  number  in  accord- 
ance with  the  abundance  of  the  exudation.  The  copious  fibrin- 
ous exudation  of  the  synovial  membrane  which,  in  some  forms 
of  joint  tuberculosis,  characterizes  the  type  of  the  disease  is  well 
shown  in  Fig.  27. 

It  is  very  easy  to  see  how,  in  cases  of  this  kind,  loose 
bodies  form  by  separation  of  these  projections.  Schuchardt 
("  Ueber  die  Reiskorperchenbildungen  in  Sehnenscheidem  und 
Gelenken."  Virchow's  Archiv,  B.  cxiv,  Heft  1,  p.  186),  in  a 

lengthy  and  exhaustive  treatise 
upon  the  origin,  formation,  and 
nature  of  these  bodies  in  joints 
and  tendon-sheaths,  maintains 
that  they  are  not  composed  of 
ordinary  fibrin,  and  cannot  be 
considered  in  any  case  to  be  pro- 
duced by  coagulation  necrosis  of 
the  inflammatory  material  de- 
posited upon  the  surface  of  the 
internal  wall  of  the  cavity  of  the 
joint  or  tendon-sheath.  He  does 
not  believe  that  the  villous 
and  papillomatous  growths  found 
within  some  hygromas  are  the  main  cause  of  the  free  riziform 
bodies  often  associated  with  this  condition ;  for,  even  where 
such  villous  outgrowths  are  present  they  may  bear  no  relation 
to  the  free  bodies,  and  the  rapidity  with  which  these  bodies 
sometimes  reform  after  the  sac  has  been  evacuated  argues 
against  their  passing  through  a  stage  of  villous  excrescence. 
Indeed,  he  has  found  the  wall  of  a  ganglion  largely  composed 
of  agglutinated  and  flattened,  half-formed  rice-bodies.  The 
size  and  form-  of  these  bodies  are  doubtless  mainly  determined 
by  the  movements  to  which  they  are  subjected,  so  that  when 
mobility  of  the  parts  is  slight  they  form  less  readily  than  when 


FIG.  27.— EXTIRPATED  PIECE  OP 
CAPSULE  OF  KNEE-JOINT,  SHOWING 
NUMEROUS  PAPILLOMATOUS  PROJEC- 
TIONS. (Konig.) 


SPECIAL   POINTS   IN   PATHOLOGY  OF   SYNOVIAL   TUBERCULOSIS.       147 

it  is  free  and  marked.  Examined  by  Jalagnier,  they  were  found 
to  be  developed  upon  the  surface  of  the  synovial  sheath ;  later, 
being  pushed  out,  and  finally  becoming  detached  from  the 
surface  upon  which  they  originated. 

Tillmanns  ("  Beitrage  zur  Histologie  der  Gelenke,"  Archiv 
f.  Mikr.  Anatomie,  1874,  B.  x,  pp.  425-436)  has  described, 
from  a  histological  point,  synovial  villi  or  papillae  composed  of 
myxomatous,  fibrous,  fibro-myxomatous,  and  adipose  tissue,  all 
having  the  common  structure  of  being  covered  by  several  layers 
of  intima-cells.  The  proliferation  evidently  takes  place  from 
the  adventitia  of  the  synovial  membrane.  The  more  these 
papillae  project  into  the  joint,  the  more  the  cellular  covering 
suffers  from  pressure  and  friction.  The  tissue  of  which  they 
are  composed  resembles  more  and  more  fibroma,  and  after  they 
project  some  distance  beyond  the  surface  pedunculation  takes 
place,  and  the  papillary  fibroma  of  the  synovial  membrane,  as 
described  by  Virchow  (Die  Kranlthaften  Geschwiilste,  Berlin, 
B.  i,  p.  340),  has  formed.  The  synovial  membrane  is  often 
found  covered  by  hundreds  and  thousands  of  such  papillary 
excrescences. 

Wallich  (La  Semaine  Medicale,  November  21,  1888), 
though  unable  to  discover  bacilli  in  rice-bodies,  succeeded,  by 
inoculation,  in  producing  tuberculosis  in  guinea-pigs  with  them. 
I  have  repeatedly  verified  the  tubercular  nature  of  such  loose 
bodies  in  tubercular  joints  and  tendon-sheaths  by  successful 
implantation  experiments. 

Tubercular  Chondritis. — The  absence  of  blood-vessels  and 
other  vascular  spaces  in  cartilage  is  the  reason  why  this  tissue 
is  seldom  the  seat  of  a  primary  tuberculosis.  Cartilage  is,  in 
every  sense  of  the  word,  a  non-vascular  structure,  as  even  the 
plasma-channels  found  in  the  cornea  are  absent  here.  Nutrition 
of  this  structure  must  take  place  exclusively  by  imbibition  be- 
tween or  through  the  cells.  That  such  parenchymatous  diffusion 
through  this  tissue  takes  place  was  known  to  Cruveilhier,  who 
injected  ink  into  the  joints  of  animals,  and  found  some  time 


148  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

afterward  that  the  cartilage  was  deeply  stained,  while  the  ink 
had  been  removed  from  the  synovial  sac  by  absorption.  In  the 
same  manner  living  cartilage  can  be  stained  a  red  color  by 
injecting  into  joints  a  borax-lithion-carmine  solution.  While 
normal  cartilage  is  an  avascular  structure,  it  is  supplied  with 
blood-vessels  from  the  perichondrium,  like  the  cornea  from  the 
pericorneal  blood-vessels  when  the  seat  of  irritation  or  inflam- 
mation. Gussenbauer  studied  the  repair  of  cartilage  wounds 
experimentally  on  costal  cartilage  of  animals.  He  made  sub- 
cutaneous incisions,  and  then  examined  the  specimens  from  a 
few  hours  to  several  weeks  after  the  injury  had  been  inflicted. 
In  wounds  twenty-four  hours  old  a  triangular  gap  was  found, 
filled  with  fibrin  and  blood-corpuscles.  No  change  was  found 
at  this  time  in  the  cartilage  cells  and  cement-substance.  Evi- 
dences of  beginning  repair  he  found  in  the  vascular  perichon- 
drium, the  cells  of  which  had  increased  in  size  and  changed  in 
form.  He  was  unable  to  verify  the  observations  made  by  Reitz, 
in  wounds  of  the  trachea,  that  cartilage  cells  are  transformed 
into  connective-tissue  cells,  and  believes  that  the  ammonia  used 
by  Reitz  to  provoke  croupous  pneumonia,  by  its  introduction 
into  the  bronchial  tubes  through  the  trachea!  wound,  may  have 
modified  the  result.  He  traces  tissue-proliferation  almost  ex- 
clusively to  the  perichondrium.  the  cells  of  which  were  found  in 
all  stages  of  division  and  development,  while  only  a  few  of  the 
cartilage  cells  presented  evidences  of  karyokinetic  changes. 
Dorner  studied  not  only  the  manner  of  repair  of  simple  incised 
wounds  of  cartilage,  but  also  produced  more  complicated  in- 
juries, and  invariably  found  that  the  perichondrium  took  a  more 
active  part  in  the  process  of  healing  than  the  cartilage  cells. 
The  histological  changes  observed  by  Redfern,  Dorner,  and 
Gussenbauer,  during  the  repair  of  wounds  of  cartilage  produced 
experimentally,  are  descriptive  of  the  minute  anatomy  of  chon- 
dritis.  In  the  early  stages  of  pannous  synovitis  the  articular 
cartilages  are  supplied  with  blood  from  the  synovial  membrane, 
and  in  other  localities  the  inflammatory  process  begins,  like  the 


SPECIAL   POINTS   IN  PATHOLOGY  OF  SYNOVIAL  TUBERCULOSIS.       149 

suppurative  process,  in  the  perichondrium,  and  invades  the 
cartilage  a  little  in  advance  of  the  net-work  of  new  blood- 
vessels. That  a  tubercular  perichondritis  occurs  as  a  primary 
affection  I  have  had  repeated  opportunities  to  verify.  In  all  of 
the  cases  of  this  kind  that  have  come  under  my  observation  the 
disease  involved  the  costal  cartilages.  The  following  case  will 
serve  as  an  illustration  : — 

The  patient  was  a  man  46  years  of  age,  without  any  he- 
reditary predisposition  to  tuberculosis.  He  was  admitted  into 
the  Milwaukee  Hospital  February  6,  1891,  and  operation  was 
performed  on  the  same  day.  The  patient  is  quite  obese,  and 
the  general  appearance  would  not  lead  to  the  suspicion  that  he 
is  the  subject  of  a  tubercular  affection.  Preceding  year,  during 
the  month  of  July,  he  suffered  from  an  attack  of  typhoid  fever. 
About  a  month  later,  after  considering  himself  fully  convales- 
cent, be  began  to  experience  an  intermitting  pain  under  the  left 
breast,  which  extended  backward  toward  the  spine.  In  Sep- 
tember a  swelling  appeared  over  the  cartilages  of  the  seventh 
and  eighth  ribs.  With  the  appearance  of  the  swelling  the  pain 
gradually  subsided.  On  admission  this  swelling  had  attained 
half  the  size  of  an  adult's  fist,  and  presented  the  usual  appear- 
ances of  a  cold  abscess.  Although  the  patient  presented  every 
evidence  of  unimpaired  health,  I  suspected  that  the  abscess  had 
developed  in  the  course  of  a  primary  tuberculosis  of  one  or 
more  ribs.  The  external  surface  presented  a  healthy  appear- 
ance, but  the  skin  was  firmly  attached  to  the  deeper  tissue  by 
inflammatory  adhesions.  The  patient  complained  of  no  pain, 
and  tenderness  on  pressure  was  only  slight.  A  semilunar 
incision  was  made  through  the  skin  and  superficial  fascia,  the 
convexity  directed  downward  so  as  to  expose  the  field  of  opera- 
tion freely  after  reflection  of  the  flap.  The  subcutaneous  tissue 
was  somewhat  cedematous.  Incision  through  the  pectoral 
muscles  evacuated  about  four  ounces  of  tubercular  pus.  The 
abscess-cavity  was  lined  with  fungous  granulations.  Two 
fistulous  tracts  led  down  to  the  cartilages  of  the  seventh  and 


150  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

eighth  ribs.  Sternum  and  ribs  intact.  Both  cartilages  were  re- 
moved in  their  entirety.  Examination  of  the.  specimens  showed 
that  they  were  denuded  of  perichondrium  on  the  anterior  sur- 
face, and  each  of  them  presented  superficial  defects,  the  size  of 
a  pea,  partly  filled  with  granulation  tissue.  The  abscess-cavity 
was  thoroughly  scraped,  iodoformized,  and  the  external  wound 
sutured,  after  making  provision  for  capillary  drainage.  The 
entire  wound  healed  by  primary  union,  the  patient  has  remained 
in  good  health,  and  there  has  been  no  sign  of  local  recurrence. 
It  is  more  than  probable  that  in  this  case  the  disease  com- 
menced as  a  tubercular  perichondritis ;  and  yet  one  or  two  cavi- 
ties were  so  deep  and  their  opening  on  the  surface  of  the 
cartilage  so  narrow  that  the  appearances  suggested  a  primary 
focus  in  the  cartilage,  with  secondary  involvement  of  the  peri- 
chondrium and  surrounding  tissues.  In  another  case  I  found 
the  costal  cartilages  of  six  ribs  the  seat  of  extensive  tuberculo- 
sis, while  the  ribs  and  sternum  were  intact.  A  thorough 
scraping  operation,  under  strict  antiseptic  precautions,  resulted 
in  a  speedy  and  permanent  cure. 

Kocher  has  described  in  the  knee-joint  meniscitis  tubercu- 
losa  as  a  primary  tuberculosis  of  the  semilunar  cartilages,  but 
there  is  no  positive  evidence  that  the  disease  did  not  commence 
in  the  synovial  membrane  covering  these  structures.  In  tuber- 
culosis of  joints  the  alteration  of  the  articular  cartilages  is 
caused  by  the  action  of  tubercular  tissue  upon  them  from  the 
synovial  membrane,  or  from  the  subjacent  bone,  the  cartilage 
taking  no  active  part  in  the  process.  The  cartilage  is  often 
completely  destroyed  by  the  granulations  which  frequently  act 
upon  it  from  both  sides. 

It  is  removed  by  the  granulations  somewhat  in  the  same 
manner  as  a  disc  of  aseptic  decalcified  bone,  only  that  its  ab- 
sorption is  accomplished  by  a  much  slower  process.  The  most 
common  changes  found  in  it  are  thinning  and  multiple  defects. 
These  changes  are  most  marked  and  appear  earliest  where  the 
synovial  membrane  joins  the  cartilage,  as  at  the  edges  of  the 


LfRPTPY  GF 

SPECIAL  POINTS   IN   PATHOLOGIC  ffl  jSYN^VIAL  TUBERCUJLQS^ 

cartilage,  at  the  points  of  attachment  of  the  crucial  ligaments  in 
the  knee-joint,  in  the  neighborhood  of  the  ligamentum  teres  in 
the  hip-joint,  etc.  In  primary  disease  of  the  synovial  membrane 
the  cartilage  often  remains  intact  for  a  long  time  in  all  cases 
in  which  the  intrinsic  tendencies  of  the  disease  are  to  remain 
limited  to  the  synovial  structure,  while  in  others  the  extension 
of  the  tubercular  process  to  the  cartilage  is  an  early  occurrence. 
The  chondritis  is  preceded  by  extension  of  the  vascular  synovial 
membrane  in  the  form  of  a  pannus  over  it,  which  converts  the 
cartilage  first  into  fibro-cartilage  and  later  into  fibrous  tissue,  and 
the  new  tissue  then  formed  becomes  subsequently  infiltrated  with 


Fio.  28.— PRIMARY  OSSEOUS  TUBERCULOSIS  OF  HEAD  OF  FEMUR.    (Krause.) 

Perforation  into  joint  at  b ;  secondary  synovial  tuberculosis  which  has  resulted,  at  a,  in  circumscribed 
destruction  of  articular  cartilage. 

tubercular  tissue  from  the  synovial  membrane  or  bone,  and  under- 
goes the  characteristic  degenerative  processes.  At  some  points  the 
soft  tissues  proliferate  more  actively,  and  thus  islets  of  granula- 
tion tissue  are  seen  to  fill  minute  excavations  in  the  cartilage. 
At  other  points  the  granulations  from  the  end  of  the  bone 
undermine  and  separate  the  cartilage.  In  primary  osseous 
tuberculosis  of  the  articular  extremities  the  subchondral  foci 
detach  and  elevate  (Fig.  26)  the  cartilage ;  this  separation  is 
often  quite  extensive,  as  the  tubercular  process  between  the 
bone  and  cartilage  is  often  diffuse  before  perforation  takes  place 
and  keeps  on  extending  after  this  accident  has  occurred.  The 
osseous  focus,  when  it  has  reached  this  locality,  gives  rise  to 


152[KT/V-"KTOBERCULOSIS   OF   THE   TONES   AND   JOINTS. 

granulating  osteomyelitis  of  the'  articular  surface  of  the  bone, 
which,  as  a  rule,  involves  the  bone  only  to  a  depth  of  a  few 
millimetres,  and  only  in  exceptional  cases  is  the  entire  head  of 
the  bone  affected.  The  detached  cartilage  becomes  macerated 
by  the  tubercular  product  in  the  joint.  In  tubercular  infarcts 
invading  joints  the  cartilage  covering  the  base  of  the  wedge- 
shaped  sequestrum  is  destroyed  early,  and  if  the  patient  con- 
tinues to  use  the  limb  the  articular  portion  of  the  necrosed  bone 
presents  a  dense,  polished  surface.  In  diffuse  tubercular  osteo- 
myelitis, if  the  plate  of  articular  cartilage  is  detached,  the  ex- 
posed surface  of  the  bone  will  be  found  covered  with  pale,  red, 
flabby  granulations  growing  out  from  the  bone.  If  the  disease 
has  extended  at  the  same  time  to  the  medullary  cavity  the  mar- 
row appears  very  vascular,  as  it  has  been  transformed  into 
granulation  tissue, — a  condition  which  Konig  has  observed  most 
frequently  starting  from  the  shoulder-joint,  involving  the  shaft 
of  the  humerus. 

Weichselbaum  ("  Die  feineren  Veranderungen  des  Gelenk 
knorpels  bei  fungoser  Synovitis  u.  Caries  der  Gelenkenden." 
Virchow's  Archiv,  B.  Ixxii,  p.  110)  has  studied  and  described 
with  great  care  the  minute  tissue  changes  which  take  place  in 
the  articular  cartilages  in  tubercular  joints.  In  tubercular  syno- 
vitis  an  inflammatory  process  is  initiated  in  the  periphery  of  the 
cartilage,  and  at  first  in  the  most  superficial  cells,  which  con- 
sists in  the  proliferation  of  new  cells.  The  new  cells  are  gran- 
ular, nucleated,  and  provided  with  processes.  The  spaces  in 
which  these  cells  are  found  become  enlarged  and  confluent,  and 
result  in  the  formation  of  minute  linear  depressions  on  the  sur- 
face. In  this  manner  a  sort  of  granulation  tissue  is  formed, 
which  coalesces  with  the  synovial  granulations.  In  this  way 
the  cartilage  may  become  completely  destroyed,  the  process 
extending  from  the  periphery  toward  the  centre.  In  caries  of 
the  articular  ends  the  cartilage  cells  nearest  the  bone  undergo 
regressive  metamorphosis,  and  their  place  is  taken,  step  by  step, 
by  granulation  tissue  springing  from  the  medullary  spaces. 


SPECIAL   POINTS   IN  PATHOLOGY  OF   STNOVIAL   TUBERCULOSIS.       153 

According  to  Weichselbaum,  at  a  later  stage  the  cartilage  cells 
take  an  active  part  in  the  inflammatory  process,  and  the  granu- 
lations from  both  sources  meet  and  form  a  common  subchondral 
product. 

Pathological  Changes  in  Bone  in  Joint  Tuberculosis. — The 
gravity  of  the  secondary  bone-lesions  depends  on  the  extent  and 
duration  of  the  disease.  Atrophy  of  the  bone  is  a  conspicuous 
feature  in  all  cases  of  long  standing,  and  more  especially  if  the 
location  or  extent  of  the  disease  has  necessitated  prolonged  and 
enforced  rest.  Such  specimens  present  characteristic  appear- 
ances, the  cortical  portion  being  very  much  thinner  than  in  the 
normal  condition,  and  the  spongy  portion  greatly  rarefied  and 
softened.  Not  infrequently,  simple  atrophy  has  been  mistaken 
for  disease,  and  an  unnecessary  amount  of  tissue  has  been  sac- 
rificed in  resections  and  amputations  for  tuberculosis.  These 
changes  are  not  the  result  of  inflammation,  but  develop  in  con- 
sequence of  defective  nutrition  incident  to  long-continued  rest. 
Cases  occur,  however,  in  which  inflammatory  changes  are  found 
in  bone  independently  of  and  remotely  from  tubercular  foci.  In 
these  cases  we  have  to  deal  with  a  granulating  osteomyelitis  of 
the  articular  extremities,  which,  as  a  rule,  starts  from  the  in- 
flammatory border  of  the  synovial  membrane.  The  amount  of 
bone  destruction  in  tubercular  joints,  aside  from  that  brought 
about  by  the  inflammation,  is  determined  mainly  by  mechanical 
injuries,  to  which  the  joint  is  so  often  subjected.  The  muscular 
contractions  which  attend  every  inflammatory  affection  of  joints 
in  which  the  bony  structures  are  concerned  aggravate  the  intra- 
articular  pressure  at  some  points  and  add  pressure-atrophy  to 
the  loss  of  substance  caused  by  inflammation.  The  rim  of  the 
acetabulum  often  makes  a  furrow  in  the  softened  head  of  the 
femur,  even  if  its  cartilaginous  covering  has  not  undergone  any 
appreciable  changes.  (Fig.  16,  d.)  The  loss  of  tissue  pro- 
gresses more  rapidly  after  the  articular  cartilage  has  disappeared 
under  the  increased  pressure,  while  the  inflammation  penetrates 
deeper  into  the  substance  of  the  bone.  In  acetabular  disease 


154  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

of  the  hip-joint  the  pressure  of  the  head  of  the  femur  against 
the  upper  rim  not  infrequently  causes  such  an  extensive  destruc- 
tion that  the  acetabulum  becomes  first  greatly  elongated,  allow- 
ing the  head  of  the  femur  to  wander  in  an  upward  and  back- 
ward direction  until  a  pathological  dislocation  is  effected.  In 
other  instances  the  limb  is  gradually  shortened  an  inch  or  more, 
but  dislocation  is  prevented  by  the  formation  of  osteophytes 
above  the  rim  of  the  acetabulum,  brought  about  by  a  plastic 
periostitis  in  that  locality.  Specimens  of  this  kind  present  stal- 
actitic  spurs  of  bone,  which  embrace  and  support  the  head  of 
the  femur  in  its  abnormal  locality.  These  destructive  changes 
are  hastened  by  suppuration ;  in  fact,  the  suppuration  transforms 
the  softened  fungous  surfaces  of  the  articular  ends  of  the  bones 
into  ulcerating  surfaces.  In  advanced  cases  of  primary  synovial 
tuberculosis  both  articular  surfaces,  as  a  rule,  become  affected 
as  soon  as  the  articular  cartilages  have  been  removed  by  the 
disease.  The  absorption  of  bone  and  molecular  necrosis  in 
this  condition  was  formerly  known  and  described  as  caries,  but 
is  now  known  as  fungous  or  tubercular  osteomyelitis.  If  case- 
ation  and  the  formation  of  a  tubercular  abscess  do  not  take 
place  a  spontaneous  cure  is  still  possible,  but  will  always  result 
in  bony  ankylosis,  with  impairment  of  function  of  the  limb. 
In  tubercular  spondylitis  further  extensive  bone  destruction  is 
caused  by  the  weight  of  the  body  above  the  seat  of  the  disease, 
resulting  in  pressure-atrophy,  and  it  is  owing  to  this  factor  that 
the  bodies  of  the  affected  vertebrae  become  wedge-shaped,  the 
apex  of  the  wedge  being  directed  forward,  which,  if  two  or 
more  vertebrae  are  affected  in  a  similar  manner,  gives  rise  to 
the  characteristic  posterior  curvature.  In  central  tubercular 
osteomyelitis  of  the  long  oones  of  the  hand  and  foot  the  tuber- 
cular product  causes  rarefaction  and  distension  of  the  shaft, 
which  gives  rise  to  the  spindle-shaped  enlargement  familiarly 
known  as  spina  ventosa.  If  the  disease  does  not  come  to  a 
stand-still  spontaneously,  or,  by  appropriate  treatment,  perfo- 
ration of  the  bone  finally  takes  place,  usually  about  the  centre 


SPECIAL   POINTS   IN   PATHOLOGY  OF    SYNOVIAL   TUBERCULOSIS.       155 

of  the  swelling,  which  is  followed  by  tubercular  periostitis  and 
the  formation  of  a  paraperio steal  abscess. 

Para-articular  Tubercular  Abscess. — Tubercular  abscesses 
in  the  immediate  vicinity  of  the  joint  rarely  form  independently 
of  an  articular  or  osseous  tubercular  focus. 

Bidder  ("  Beobachtungen  iiber  parasynoviale  Scrophulose 
Abscesse  am  Kniegelenk."  Deutsche  Zeitschrift  f.  Chirurgie, 
B.  xvi)  repotts  two  cases  of  parasynovial  or  peri-articular  abscess 
of  the  knee  in  which  an  affection  of  the  joint  could  be  posi- 
tively excluded.  Such  cases  are  exceedingly  rare.  The  diag- 
nosis must  be  based  upon  the  absence  of  effusion  in  the  joint; 
the  articular  ends  of  the  bones  show  no  points  of  tenderness  on 
pressure,  and  the  movements  of  the  joint  are  not  much  impaired. 
Such  abscesses  may  implicate  the  joint  secondarily  by  the  exten- 
sion of  the  tubercular  process  through  the  capsule  to  the  syno- 
vial  membrane.  Bidder  reports  a  case  where  he  had  reason  to 
believe  that  this  occurred.  So  constantly  is  a  primary  tubercu- 
lar affection  of  the  joint  or  bone  associated  with  para-articular 
abscess  that  from  the  presence  of  the  latter  the  existence  of  one 
or  both  conditions  may  be  safely  assumed.  In  tubercular 
empyema  of  joints,  perforation  of  the  capsule  leads  speedily  to 
the  formation  of  an  abscess  outside  of  the  joint,  which  at  once 
changes  some  of  the  clinical  aspects  of  the  case.  The  swelling 
of  the  joint  is  diminished,  while  a  new  swelling  appears  at  the 
seat  of  perforation  with  all  the  characters  of  a  cold  abscess.  If 
pain  was  a  well-marked  feature  before  rupture  of  the  capsule 
occurred,  this  is  relieved  by  the  accident,  on  account  of  the 
sudden  diminution  of  the  intra-articular  pressure.  In  some 
cases  an  intra-osseous  focus  first  involves  the  adjacent  joint, 
after  which  the  process  extends  from  here  to  the  para-articular 
tissues ;  in  other  instances  the  para-articular  affection  depends 
exclusively  on  a  primary  synovial  tuberculosis,  while  in  a  third 
class  the  communication  with  a  primary  osseous  focus  may  be 
direct  without  involvement  of  a  joint.  (Fig.  21.)  Under 
favorable  circumstances,  the  communication  between  a  para- 


156  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

articular  abscess  and  a  tubercular  joint  may  become  obliterated 
and  a  spontaneous  cure  may  follow.  During  an  operation  for 
para-articular  abscess,  it  is  often  very  difficult  to  find  and  follow 
the  communicating  tract  leading  to  the  joint  or  bone ;  usually, 
however,  the  tubercular  path  can  be  recognized  and  made 
accessible  to  radical  treatment.  After  the  tubercular  process 
has  extended  from  the  bone  to  the  periosteum,  or  from  the  joint 
beyond  the  limits  of  the  capsule,  it  spreads  along  the  connective- 
tissue  spaces  between  muscles,  and  along  tendons,  vessels,  nerves, 
and  finally  reaches  the  skin,  in  which  a  circular  defect  is  pro- 
duced, through  which  the  contents  of  the  abscess  escape.  The 
opening  thus  formed  shows  no  tendency  to  heal,  and  soon 
becomes  lined  with  fungous  granulations.  As  this  external 
opening  is  usually  some  distance  from  the  primary  disease,  and 
the  early  location  of  the  para-articular  abscess  is  often  difficult 
and  sometimes  impossible,  it  is  not  easy  to  follow  the  fistulous 
tract  with  a  probe  into  the  interior  of  the  abscess  and  to  locate 
accurately  the  primary  seat  of  the  disease. 


CHAPTER  XVI. 

ETIOLOGY. 

A  GREAT  deal  that  has  been  said  in  reference  to  the  causa- 
tion of  bone  tuberculosis  applies  with  equal  force  to  the  elucida- 
tion of  the  etiology  of  tubercular  inflammation  of  joints.  I 
will  discuss  here  mainly  the  hereditary  origin  of  the  affection. 
All  of  the  old  and  most  of  the  modern  authors  recognize 
heredity  as  one  of  the  most  frequent  and  potent  causes  in  the 
production  of  tubercular  disease  of  joints.  Bryan  Crowthers 
("  Practical  Observations  on  the  Diseases  of  the  Joints,  com- 
monly called  White  Swellings,"  etc.  London,  1808),  in  the 
introduction  to  his  interesting  book,  expresses  himself  as  follows, 
in  support  of  hereditary  influences  in  the  causation  of  white 
swellings :  "I  shall  forbear  to  inquire  whether  scrofula  ought 
strictly  to  be  called  a  hereditary  disease  or  not ;  of  the  following 
facts,  however,  I  am  quite  certain,  that  most  of  the  patients 
whom  I  have  seen  afflicted  with  white  swelling  were  of  a  stru- 
mous  habit,  and  were  descended  from  parents  of  a  similar  con- 
stitution. Many  members  of  such  families  have  been  destroyed 
by  pulmonary  consumption  ;  and,  if  one  parent  be  healthy  and 
the  other  of  a  scrofulous  habit,  one  child  produced  by  such 
union  shall  escape  free,  while  the  remainder  are  miserably 
attacked  with  the  complaint,  and  the  children  will  bear  a  strong 
resemblance  in  features  to  that  parent  whom  they  resemble  in 
constitution." 

Dollinger  (Wiener  Med.  Wochenschrift,  April  27,  1889), 
from  a  careful  investigation  into  the  antecedents  of  twenty-five 
cases  of  tuberculosis  of  bone,  found  that  in  more  than  one-ihird 
of  them  one  or  more  of  the  immediate  ancestors  had  suffered 
from  pulmonary  phthisis ;  so  that  lie  has  come  to  the  conclusion 
that  the  influence  of  the  tubercular  virus  must  be  exerted 
through  several  generations  before  the  normal  resistance  of  the 
osseous  structures  is  so  far  weakened  that  they  become  a  suitable 

(157) 


158  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

soil  for  the  arrest  and  development  of  the  tubercle  bacillus; 
in  other  words,  that  in  hereditary  tuberculosis  the  lungs  are 
attacked  in  the  first,  the  bones  and  joints  in  the  second  genera- 
tion. Of  five  hundred  and  ninety-six  cases  of  hip-joint  disease 
analyzed  by  Gibncy  ("  The  Hip  and  its  Diseases,"  p.  220.  New 
York,  1884)  with  reference  to  hereditary  and  six  hundred  and 
fourteen  with  reference  to  an  acquired  diathesis,  he  succeeded 
in  finding  only  one  case  of  which  it  could  be  surely 'said  there 
was  no  struma  complicating.  He  states,  further,  that  he 
believes  that  a  slight  injury  often  develops  or  acts  as  exciting 
cause,  but  never  induces  the  disease  unless  a  predisposing  cause 
be  present.  It  is  difficult  to  understand  what  writers  and 
teachers  in  the  past,  and  many  of  them  at  the  present  time, 
mean  when  they  speak  of  such  predisposing  hereditary  causes. 
Some  of  them  assume  that  it  consists  in  a  peculiar  vulnerability 
of  the  tissues  transmitted  from  parent  to  child.  The  modern 
views  of  this  subject  may  be  narrowed  down  to  two  suppo- 
sitions: 1.  Transmission,  from  parents  to  child,  of  a  predispo- 
sition to  tubercular  disease.  2.  Transmission,  from  parents  to 
foetus,  of  the  essential  microbic  cause, — the  bacillus  of  tubercu- 
losis. The  supposed  hereditary  predisposition  is  interpreted  as 
meaning  anatomical  or  physiological  defects  in  the  tissues,  which 
render  the  organism  susceptible  to  the  action  of  subsequent 
specific  microbic  causes.  The  existence  of  minute  anatomical 
defects  of  blood-vessels,  lymphatic  glands  and  vessels,  connect- 
ive-tissue spaces,  etc.,  are  looked  upon  as  conditions  which  favor 
localization  of  floating  microbes,  which  find  their  way  into  the 
body  during  post-natal  life.  An  inherited  defective  vital  resist- 
ance on  the  part  of  the  tissues  to  the  action  of  pathogenic  bac- 
teria is  also  considered  by  many  in  the  light  of  an  hereditary 
influence  in  the  causation  of  disease.  These  conditions  are 
recognized  as  hereditary  influences  in  the  causation  of  tubercu- 
losis, but  no  satisfactory,  demonstrative,  or  experimental  proofs 
of  their  existence  have  been  furnished ;  and  yet,  the  immunity 
of  some  animals  and  persons  to  certain  diseases  cannot  be 


ETIOLOGY.  159 

explained  in  any  other  way  than  in  attributing  it  to  some 
anatomical,  physiological,  or  chemical  properties  of  the  tissues, 
which  protect  the  organism  against  the  action  of  certain  micro- 
organisms which,  in  other  animals  not  so  protected,  produce 
tuberculosis. 

Clinical  experience  has  also  shown  that  a  great  difference 
is  found  among  different  persons  in  reference  to  susceptibility 
to  the  same  form  of  infection.  In  many  persons,  for  instance, 
inoculation  with  a  pure  culture  of  tubercle  bacilli  would  be  a 
perfectly  harmless  procedure ;  in  others  it  would  produce  a 
local,  latent  tuberculosis ;  while,  in  a  few,  rendered  more  sus- 
ceptible to  this  form  of  infection  by  antecedent  hereditary  or 
acquired  causes,  the  inoculation  of  the  same  number  of  bacilli 
would  be  followed  by  rapid  and  extensive  destruction  of  tissue, 
and  death  from  early  and  diffuse  dissemination.  If  their  exist- 
ence has  not  been  demonstrated  by  clinical  observation  and 
experimental  research,  we  are,  nevertheless,  forced  to  recognize 
the  influence  of  certain  as  yet  unknown  conditions  and  influences 
inherent  in  the  tissues,  and  often  traceable  to  an  hereditary 
cause,  which  favor  or  resist  the  action  of  the  tubercle  bacillus. 
During  the  last  few  years  great  progress  has  been  made  in  show- 
ing that  hereditary  disease,  in  many  instances,  at  least,  is  due  to 
a  more  direct  cause, — the  transmission  from  parent  to  foetus  of 
the  essential  microbic  cause  of  tuberculosis.  This  method  of 
infection  is  not  only  interesting  from  a  scientific  stand-point, 
but  is  of  the  greatest  practical  importance,  alike  to  the  surgeon 
and  physician,  in  regard  to  prophylaxis,  diagnosis,  and  treat- 
ment of  tuberculosis.  Although  our  knowledge  of  the  intra- 
uterine  origin  of  tuberculosis  is  yet  imperfect  and  fragmentary, 
there  can  be  no  doubt  that  future  study  and  research  will  clear 
up  many  existing  dark  points,  and  furnish  a  satisfactory  demon- 
strative explanation  of  the  direct  and  indirect  transmission  of 
the  bacillus  of  tuberculosis  in  the  causation  of  this  disease. 
One  of  the  first  positive  demonstrations  of  direct  transmission 
of  tuberculosis  from  parent  to  offspring  was  furnished  by 


160  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

Curt  Jani  (JLondon  Lancet,  September  4,  1886,  p.  455). 
He  examined  the  healthy  sexual  organs  of  nine  male  phthisical 
patients  for  tubercle  bacilli.  No  bacilli  were  found  in  any  of 
these  in  the  semen  from  the  vesiculse  seminales ;  but,  on 
the  other  hand,  in  five  out  of  eight  cases  a  few  were  found 
in  the  testicle,  and  in  four  out  of  six  in  the  prostate.  The  tes- 
ticles and  prostate  appeared  healthy  in  structure.  He,  further, 
examined  two  women  who  died  of  pulmonary  phthisis,  the 
ovaries  in  both  presenting  negative  results.  In  one  case  of 
chronic  pulmonary  phthisis,  with  extensive  intestinal  tubercu- 
losis, he  examined  the  Fallopian  tubes  and  found  tubercle 
bacilli.  He  is  of  the  opinion  that  bacilli  can  be  transmitted 
from  parents  to  foetus  in  one  of  two  ways:  (1)  through  the 
semen  of  the  male ;  (2)  through  the  migration  of  bacilli  into 
the  uterus  from  the  Fallopian  tubes.  Infection  of  the  impreg- 
nated ovum  by  the  placental  circulation,  he  thinks,  must  be 
unusual,  because  the  examination  of  the  body  of  a  woman,  five 
months  pregnant,  who  died  from  acute  miliary  tuberculosis,  in 
whom  infection  took  place  through  the  growth  of  a  caseous 
mass  in  the  pulmonary  vein,  showed  that  there  were  no  bacilli, 
either  in  the  placental  attachment,  in  the  lungs,  or  in  any  of 
the  organs  usually  the  seat  of  localization  in  the  embryo.  He, 
however,  considers  that  it  is  by  no  means  certain  that,  in 
chronic  miliary  tuberculosis,  deposits  may  not  form  in  the 
neighborhood  of  the  placenta,  and  thus  infect  the  foetus.  Tu- 
berculosis of  the  genital  organs  of  the  female  has  been  described 
by  Zweigbaum  (  Centralblatt  f.  Bacteriologie  u.  Parasitenlcunde, 
B.  xi,  p.  558),  Barbier  (Gaz.  Medicale,  No.  39,  1888),  Kotschau 
(ArcJiivf.  Gynwlcoloc/ie,  B.  xxxi,  Heft  2),  Werth  (ibid.,  July  20, 
1889),  Jonin  (Bulletin  Paris  Obstet.  and  Gynaecological  So- 
ciety, March,  1889),  and  others.  Tubercular  affections  of  the 
organs  of  reproduction  of  the  male  have  been  studied  by  Dah- 
nar,  Kraske,  Albers,  Jaye,  Naumann,  Humphrey,  Kocher, 
Rayer,  Cruveilhier,  Reclus,  Ullman,  and  Striimpell.  Jani  found 
typical  tubercular  products  in  the  foetus  of  a  cow  that  died  of 
tuberculosis. 


ETIOLOGY.  161 

Charrin  ("  Tuberculose  Generalisee  chez  un  foetus  de  sept 
mois  et  demi."  Lyon  Medicate,  No.  14,  1873)  describes  a  case 
where  a  woman,  29  years  of  age,  without  a  hereditary  history 
of  tuberculosis  in  her  family,  suffered  from  pleuritis  during  the 
fourth  month  of  pregnancy,  which  was  followed  by  a  cheesy 
pneumonia.  She  was  delivered  of  a  foetus  seven  and  one-half 
months  old,  which  died  on  the  third  day.  The  post-mortem  ex- 
amination of  the  foetus  revealed  tuberculosis  of  the  liver,  spleen, 
and  mesenteric  glands.  The  mother  died  soon  after  the  delivery, 
and  the  autopsy  showed  advanced  pulmonary  tuberculosis. 

Birch-Hirschfeld  (Wiener  Med.  Blatter,  No.  17,  1891) 
relates  a  case  in  which  a  foetus  was  removed  from  the  uterus  of 
a  woman,  aged  23,  within  a  few  moments  of  her  death  from  gen- 
eral tuberculosis,  without  any  damage  being  done  to  the  pla- 
centa. Portions  of  the  liver,  spleen,  and  kidneys  of  the  foetus 
produced  tuberculosis  when  inoculated  into  rabbits  and  guinea- 
pigs,  but  only  in  the  capillaries  of  the  liver  could  tubercle  bacilli 
be  discovered.  In  the  placenta,  however,  the  villous  spaces  were 
crowded  with  bacilli.  TJie  very  meagre  evidences  of  bacilli  in 
the  ftetus  might  serve  as  an  explanation  of  the  fact  that  chil- 
dren of  tubercular  parents  are  often  born  without  any  mani- 
festation of  tubercular  disease,  and  yet  appear  to  develop  tuber- 
cle during  the  first  few  years  of  life.  A  limited  infection  by 
maternal  bacilli,  perhaps  during  the  progress  of  birth,  might 
remain  latent  in  one  or  more  organs  until  other  circumstances 
contribute  to  their  development.  It  is  thus  possible  that  con- 
fusion may  exist  between  "  latent  tuberculosis"  and  "  tubercular 
predisposition" 

I  am  firmly  convinced  that  direct  infection  from  parent  to 
child  occurs  more  frequently  than  is  generally  supposed,  and 
that  many  of  the  later  manifestations  of  tuberculosis  are  attrib- 
utable to  this  source.  Floating  bacilli  in  the  blood  of  infants 
may  do  no  harm  until  a  locus  minoris  resistentice  is  created  by  a 
slight  injury  or  by  acquired  pathological  conditions  after  birth. 
Post-natal  infection  through  abrasions  of  the  skin  or  exposed 


u 


162  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

mucous  surfaces  in  children  coming  in  contact  with  tubercular 
patients  is  also  a  frequent  source  of  tubercular  disease  of  bones 
and  joints.  It  is  not  necessary  or  essential,  in  such  cases,  that 
a  tubercular  lesion  should  be  produced  at  the  point  of  invasion, 
as  the  bacilli  may  reach  the  general  circulation  through  the 
infection-atrium  without  causing  a  surface  lesi.on,  and  become, 
later,  localized  in  a  joint  predisposed  to  tuberculosis  by  congen- 
ital defects  or  accidental  pathological  conditions.  We  have 
every  reason  to  believe  that  in  many  instances  the  tubercle 
bacilli  enter  the  organism  through  the  respiratory  tract  and  pro- 
duce tubercular  arthritis  in  joints  which  have  been  rendered 
susceptible  to  this  affection  by  injury,  or  antecedent  or  coinci- 
dent disease.  In  children,  infection  is  often  traceable  to  inges- 
tion  of  milk  contaminated  by  tubercle  bacilli,  and  in  such  cases 
localization  in  joints  takes  place  in  the  same  manner  as  when 
the  essential  cause  gains  entrance  through  the  skin  or  the  re- 
spiratory organs.  The  influence  of  trauma  in  the  production  of 
joint  tuberculosis  is  the  same  as  in  the  causation  of  the  same 
disease  in  bone.  Here,  as  in  bone,  a  severe  injury  is  seldom 
followed  by  tuberculosis,  as  the  injuries  to  which  the  causation 
of  this  disease  are  usually  attributed  are  slight,  and  are  often 
forgotten  before  the  first  symptoms  show  themselves.  Injury 
can  only  produce  tubercular  osteomyelitis  or  arthritis  in  patients 
already  infected  with  the  essential  cause,  and  must  be  regarded 
only  in  the  light  of  an  exciting  cause.  It  must  be  assumed  that 
after  a  severe  trauma  the  energy  of  the  reactive  and  reparative 
tissue-proliferation  is  so  considerable  as  not  to  permit  the  devel- 
opment of  the  tubercle  bacilli, — a  hypothesis  for  the  admissibility 
of  which  the  behavior  of  the  lower  organisms  offers  numerous 
analogies.  On  the  other  hand,  it  would  appear  that  slight 
injuries,  combined,  perhaps,  with  extravasation  into  the  cancel- 
lous  tissue  of  bone,  slight  stjnovial  exudation,  and,  in  any  case, 
certain  changes  in  the  nutritive  conditions  of  the  affected  tissues, 
furnish  a  favorable  soil  for  the  development  of  the  tubercle 
bacilli. 


ETIOLOGY.  163 

Age  is  an  important  factor  in  the  causation  of  tubercular 
affections  of  joints.  These  affections  manifest  a  strong  predilec- 
tion for  persons  under  the  age  of  puberty.  Barwell  (';  On  Cer- 
tain Points  in  the  Etiology  of  Hip- Joint  Disease."  London 
Lancet,  August  2,  1879)  makes  the  assertion  that  he  never  met 
with  a  case  of  hip-joint  disease  that  commenced  in  a  patient 
more  than  25  years  of  age.  Only  one  case  came  under  his 
observation  where  the  patient  was  18  years  of  age;  and  the 
majority  of  patients  were  less  than  12  years  old.  He  is  of  the 
opinion  that  the  most  important  predisposing  cause  is  the  great 
vascularity  which  is  present  in  the  vicinity  of  bone-producing 
cartilage  in  young  persons.  BarwelPs  views  in  regard  to  the 
importance  of  age  as  an  etiological  factor  in  the  causation  of 
joint  tuberculosis  are  somewhat  extreme,  as  I  have  repeatedly 
had  patients  under  my  care  in  whom  the  disease  commenced 
after  40  years  of  age.  The  wrist-  and  knee-  joints  are  quite 
frequently  the  seat  of  tuberculosis  in'  persons  advanced  in  years, 
and  even  old  age  is  not  quite  exempt.  It  is  quite  often  the 
case  that  children  who  suffer  an  attack  of  tuberculosis  of  the 
lymphatic  glands  or  skin  become  later  the  victims  of  a  joint 
tuberculosis.  Yolkmann  (Centralblatt  f.  Cliirurgie,  No.  24, 
1885)  has  well  said :  "A  person  suffers  from  tuberculosis  of  the 
lymphatic  glands  in  youth,  has  a  tumor  albus  or  arthrocace 
toward  puberty,  and  dies  from  pulmonary  tuberculosis  in  the 
thirties.  This  is  very  common  and  cannot  appear  astonishing, 
since  the  susceptibility  to  the  said  virus  is  not  lessened  by  hav- 
ing withstood  a  tubercular  infection.  The  persons  in  question 
possess,  at  least  in  the  great  majority  of  cases,  an  individually- 
increased  susceptibility  to  the  virus,  and  this  is  about  them 
everywhere." 

Among  the  exciting  causes  must  be  mentioned  the  acute 
infectious  diseases.  About  fifteen  years  ago  Luecke  called 
attention  to  the  etiological  relationship  which  exists  between 
acute  infectious  diseases  and  tuberculosis  of  joints.  Keen 
(Transactions  of  the  American  Orthopcedic  Association,  vol.  ii. 


164  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

"  Typhoid  Spine,"  by  V.  P.  Gibney)  has  given  a  good  account 
of  all  bone-lesions  following  the  continued  fevers.  He  found  69 
cases,  of  which  22  affected  the  head,  7  the  trunk,  6  the  upper 
and  42  the  lower  extremities.  In  37  cases  the  disease  followed 
typhoid  fever.  As  to  the  date  of  the  occurrence,  in  47  cases,  10 
were  within  two  weeks,  27  from  three  to  six  weeks,  and  10 
some  months  after  the  fever.  Keen's  explanation  was  that  the 
earlier  cases  probably  resulted  from  thrombosis,  and  the  latter 
from  enfeebled  nutrition.  Trauma,  if  any,  in  these  cases  was 
always  slight.  These  cases  include  all  pathological  forms  of 
bone  and  joint  disease,  but  among  them  not  an  inconsiderable 
number  were  tubercular  in  their  character.  Sudden  exposure 
to  cold  is  another  etiological  element  which  should  not  be 
ignored.  Sudden  suppression  of  cutaneous  perspiration,  com- 
bined with  diminution  of  the  peripheral  circulation,  often 
brings  about  the  necessary  local  conditions  of  the  deep-seated 
vessels,  which  determine  localization  of  bacilli  from  the  blood 
in  the  articular  extremities  of  the  long  bones  and  the  soft 
structures  of  joints, — an  occurrence  which,  without  such  influ- 
ences, might  have  postponed  in'definitely  the  localization,  or  dis- 
ease might  have  been  entirely  avoided.  TCheumatism  also 
appears  to  act  as  one  of  the  predisposing  causes  to  tubercular 
synovitis.  At  the  llouen  Congress,  in  1883,  Verneuil  hinted 
at  the  possible  combination  of  the  tubercular  and  rheumatic 
diathesis  as  mutual  etiological  factors.  October,  1886.  Peyrot 
and  Jonnesco  presented  to  the  second  French  Surgical  Congress 
a  case  of  tubercular  panaris  in  an  adult,  invading  a  nodosity, 
on  a  finger,  left  by  rheumatism.  In  July,  1888,  Jonnesco  fur- 
nished another  observation  of  tubercular  arthritis  in  a  rheumatic, 
who,  in  his  infancy,  had  presented  various  enlarged  cervical 
glands,  then  passed  through  an  attack  of  acute  articular 
rheumatism,  and  finally  suffered  from  a  tubercular  arthritis  of 
the  right  knee-joint,  followed  by  a  similar  attack  of  the  left 
knee-joint.  His  father  died  of  tubercular  enteritis  at  the  age 
of  40,  and  his  mother,  aged  68  years,  was  a  confirmed  rheumatic 


ETIOLOGY.  165 

invalid.  In  brief,  the  etiology  of  tuberculosis  of  joints  may  be 
summarized  to  the  effect  that  the  essential  cause  consists  in  the 
presence  of  tubercle  bacilli,  in  sufficient  number,  in  the  soft 
structures  of  the  joint,  to  enable  them  to  exercise  their  specific 
pathogenic  properties-  upon  tissues  predisposed  to  infection  by 
hereditary  or  acquired  causes. 


CHAPTER  XVII. 

SYMPTOMS  AND  DIAGNOSIS. 

THE  clinical  study  of  joint  tuberculosis  should  precede  the 
subject  of  bone  tuberculosis,  although  the  etiological  relation 
of  the  latter  to  the  former  has  already  been  discussed.  Most 
forms  of  osseous  tuberculosis  give  rise  to  a  complexus  of  symp- 
toms characteristic  of  joint  tuberculosis.  The  symptoms  vary, 
according  to  the  type  of  the  disease  and  manner  of  infection.  In 
all  varieties  the  symptoms  and  clinical  picture  point  to  the  exist- 
ence of  a  chronic  inflammation.  With  the  exception  of  circum- 
scribed points  of  tenderness  outside  of  the  joint,  that  indicate 
the  existence  of  primary  osteotuberculosis  during  its  early 
stage,  we  have  no  symptoms  which  enable  us  to  make  a  positive 
differential  diagnosis  between  a  primary  osseous  and  a  primary 
synovia!  tuberculosis  of  a  joint.  The  primary  osseous  form  is 
the  most  common.  In  the  knee  the  proportion  of  the  primary 
osseous  to  the  primary  synovial  form  is  as  the  proportion  of  3 
to  1 ;  in  the  hip,  4  to  1 ;  in  the  elbow,  4  to  1.  As  to  age,  the 
proportion  is,  in  children  below  15  years  of  age,  2  to  1 ;  above 
15,  3  to  1.  In  reference  to  the  location  of  the  joints  affected, 
it  can  be  said  that  joint  tuberculosis  is  much  more  frequent  in 
the  lower  than  in  the  upper  extremities.  According  to  Albrecht, 
out  of  325  cases,  in  91  the  disease  affected  the  joints  of  the 
upper  and  in  234  those  of  the  lower  extremities.  A  tubercular 
arthritis  presents  so  many  characteristic  clinical  features  that  a 
correct  diagnosis  can  usually  be  made  by  a  careful  study  of 
symptoms. 

Swelling. — This  symptom  is  not  present  in  all  forms  of 
synovial  tuberculosis.  In  the  atrophic  form  of  plastic  synovitis, 
the  caries  sicca  of  Volkmann,  so  common  in  the  shoulder-joint, 
there  is  not  only  no  swelling,  but  the  region  of  the  joint  may 
even  be  found  diminished  in  size  from  muscular  atrophy.  The 
absence  of  swelling  and  the  presence  of  considerable  mobility 
(166) 


SYMPTOMS   AND   DIAGNOSIS.  167 

in  the  joint  may  lead  to  a  wrong  diagnosis,  under  the  impres- 
sion that  the  affection  is  a  neurosis.  A  careful  examination, 
under  the  influence  of  an  anaesthetic,  will,  however,  reveal 
restriction  of  mobility  from  cicatricial  contraction  of  the  tuber- 
cular capsule,  which  will  enable  the  surgeon  to  make  an  early 
and  correct  diagnosis.  In  the  other  forms  of  synovial  tubercu- 
losis more  or  less  swelling  is  always  present.  The  swelling  is 
due  either  to  effusion  into  the  joint,  thickening  of  the  capsule, 
or  para-articular  exudation.  The  swelling  resulting  from  tuber- 
cular hydrops  and  intra-articular  abscess  is  caused  almost 
exclusively  by  distension  of  the  capsule  with  fluid,  as  the  cap- 
sule in  either  case  is  but  little  thickened,  and  the  granulations 
are  scanty.  In  both  of  these  conditions  the  capsule  of  the 
joint  is  often  enormously  distended.  In  the  knee-joint  the 
patella  is  raised  from  the  condyles  of  the  femur,  and  the  depres- 
sion on  each  side  of  it,  present  in  a  normal  condition  in  the 
extended  position  of  the  limb,  is  not  only  effaced,  but  replaced 
by  a  well-marked  prominence.  Tubercular  hydrops  and  dif- 
fuse synovial  tuberculosis,  with  proliferating  disease  of  the 
synovial  membrane,  are  often  complicated  by  the  formation  of 
masses  of  fibrin  in  the  joint,  which  appear  either  as  free  bodies 
or  adherent  deposits  upon  the  synovial  membrane.  In  the 
latter  case  the  fibrin,  with  the  thickened  synovial  membrane, 
forms  a  circumscribed  swelling,  which  sometimes  can  be  located 
by  external  examination.  In  the  tuberous  variety  of  synovitis, 
the  synovial  membrane  presents  either  firm,  circumscribed 
swellings,  if  the  deeper  fibrous  portions  are  affected,  or  numer- 
ous tubercles  with  a  tendency  to  caseation.  The  presence  of 
tubers  or  fibrinous  deposits  often  occasions  the  crackling  sound 
felt  and  heard  on  moving  the  joint.  In  the  dry,  fungous 
variety  of  synovitis,  the  swelling  is  due  to  the  masses  of  granu- 
lation tissue  within,  and,  after  perforation  of  the  capsule  has 
occurred,  within  and  outside  of  the  joint.  The  uniform  soft 
swelling  is  due  more  to  the  presence  of  fungous  granulations 
than  effusion  into  the  joint,  as  the  hydrops  is  only  a  secondary, 


168  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

accidental  condition,  which,  in  the  course  of  time,  disappears 
completely. 

The  local  symptoms  are  most  conspicuous  in  diffuse  syno- 
vial  tuberculosis  with  slight  swelling  of  the  synovial  membrane 
and  capsule,  when  a  moderate  hydrops  of  the  joint  is  often  one 
of  the  earliest  and  most  prominent  symptoms.  The  tubercular 
nature  of  the  primary  lesion  frequently  becomes  evinced  by  the 
quick  re-appearance  of  the  effusion  after  tapping.  This  is  the 
most  common  of  all  the  forms  of  articular  tuberculosis.  The 
old  authors  were  of  the  opinion  that  the  oedema  in  the  neighbor- 
hood of  a  white  swelling  was  due  to  expansion  or  enlargement 
of  the  articular  extremities  of  the  bones,  until  Samuel  Cooper 
pointed  out  that  it  was  caused  by  thickening  of  the  capsule  and 
infiltration  of  the  soft  tissues  around  the  joint. 

The  invasion  of  the  para-articular  tissues  causes  consider- 
able swelling  in  the  region  of  the  joint,  imparting  to  the  latter 
the  characteristic  spindle-shape  so  frequently  found  in  the  knee-, 
elbow-,  and  ankle-  joints,  the  swelling  being  so  much  the  more 
conspicuous  when  atrophy  of  the  muscles  above  and  below  has 
taken  place.  Extension  of  the  infiltration  from  the  para-articu- 
lar tissues  in  the  direction  of  the  subcutaneous  tissues  finally 
causes  the  swollen  joint  to  be  covered  with  a  blanched,  im- 
movable, dense  skin,  giving  the  joint  the  appearance  from  which 
the  time-honored  name  of  white  swelling  was  derived.  If  a 
para-articular  abscess  appear  the  swelling  of  the  joint  is  generally 
diminished,  while  a  new  swelling  forms  in  the  vicinity  or  some 
distance  from  the  joint. 

Fluctuation, — In  tubercular  hydrops  and  intra-articular 
tubercular  abscess  this  symptom  is  well  marked ;  but  fluctuation 
is  sometimes  distinctly  felt,  and  yet  when  the  joint  is  aspirated  no 
fluid  can  be  withdrawn.  In  such  cases  the  sense  of  fluctuation  is 
given  by  masses  of  soft  granulations  within  the  joint.  Wiseman 
("  Chirurgical  Treatise,"  p.  261)  was  well  acquainted  with  the 
pseudo-fluctuation  that  is  often  felt  when  the  joint  is  distended 
with  fungous  granulations,  as  appears  from  following  passage: 


SYMPTOMS   AND    DIAGNOSIS.  169 

"But,  if  through  want  of  such  treatment  they  (joints)  grow 
excessively  swelled,  and  the  tumor  incapable  of  being  pressed 
back  or  discussed,  you  may  shrewdly  expect  the  bones  corroded; 
for,  that  swelling  is  for  the  most  part  raised  by  an  hypersarco- 
sis  within,  and  ought  not  to  be  opened  without  a  prediction  of 
a  caries,  for,  however  it  may,  by  a  seeming  fluctuation  (Italics 
my  own),  be  thought  to  have  matter,  yet,  upon  opening,  it  will 
only  discharge  a  gleet,  and  the  hypersarcosis  will  thrust  out  into 
a  fungus." 

The  difference  between  the  swelling  of  a  joint  caused  by 
inflammatory  material  and  effusion  and  the  physical  symptoms 
resulting  from  it  were  clearly  pointed  out  by  Simon  Pallas 
("  Practische  Anleitung  die  Knochen-Krankheiten  zu  heilen," 
p.  204.  Berlin  u.  Stralsund,  1770),  one  of  the  surgeons  to  the 
Charity  Hospital  in  Berlin,  as  early  as  1770,  in  the  following 
language :  "  Es  Konnen  aber  auch  allerhand  Geschwiilste 
derer  Gelenke  eine  Steifigkeit  solcher  Gelenke  herfiirbringen, 
dergleichen  sind  1  der  Gliedschwamm  (fungus  articulorum) ; 
solcher  bestehet  in  eine  unschmerzhafte,  blasse  Geschwulst  derer 
Gelenke,  welche  zwar  nachgiebt  wenn  man  mit  den  Fingern 
darauf  driicket,  Jedoch  sich  gleich  wiederum  erhebet,  sobald 
man  die  Finger  weg  thut.  Es  unterscheiden  sich  diese  Gesch- 
wiilste von  der  Wassersucht  der  Gelenke,  darinnen,  dass  erstere 
mit  rund  herum  das  Gelenk  einnehmen,  wie  letztere,  und  dass 
bei  der  Wasser  ansammlung,  die  Feuchtigkeiten  in  das  Gelenk 
selbst  angehauft  sind."  The  granulation  tissue  is  often  present 
in  such  abundance  as  to  give  rise  to  considerable  distension  of 
the  joint,  and,  in  the  knee-joint,  elevating  the  patella  from  the 
condyles  of  the  femur  to  such  an  extent  that  the  contour  of  the 
joint  simulates,  almost  to  perfection,  an  effusion  into  the  articu- 
lation. The  granulations  are  so  soft  that  on  palpation  a  sense 
of  fluctuation  can  be  distinctly  felt,  especially  if  the  capsule  of 
the  joint  is  very  thin  from  overdistension  or  destructive  changes. 
Fortunately,  we  are  now  in  possession  of  a  diagnostic  resource 
which  will  enable  us  to  make  a  positive  differential  diagnosis 


170  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

between  an  effusion  in  a  joint  and  granulating  synovitis,  and 
this  is  the  employment  of  the  exploring  syringe.  If  any  ques- 
tion remain  as  to  the  intra-articular  conditions  when  fluctuation 
can  be  elicited  on  palpating  a  diseased  joint,  this  instrument 
should  be  called  into  requisition  and  the  joint  explored  under 
strictest  antiseptic  precautions. 

Muscular  Contraction. — Contraction  of  the  flexor  muscles 
of  a  diseased  joint  is  often  one  of  the  earliest  conditions  which 
are  produced  by  tubercular  arthritis,  but  in  tubercular  hydrops 
this  symptom  is  always  absent.  In  chronic  inflammation  of 
joints  the  explanation  of  Bonnet,  that  contractions  are  caused 
by  intra-articular  pressure,  is  no  longer  tenable,  as  Luecke 
(Deutsclie  Zeitsclirift  f.  Chirurgie,  B.  xxi,  Heft  5)  has  shown 
conclusively  that  in  fungous  disease  of  joints  the  flexed  position 
is  induced  by  the  irritation  due  to  inflammation,  as  in  that 
posture  the  least  amount  of  pain  is  incurred  ;  if  the  patient  now 
attempt  to  walk  he  naturally  contracts  all  the  muscles,  so  as  to 
avoid  any  movement  which  would  aggravate  the  pain.  This 
contracted  state  of  the  muscles,  however,  tends  still  to  heighten 
the  degree  of  flexion,  as  the  flexors  are  naturally  and  anatom- 
ically stronger  and  less  easily  fatigued  than  the  extensors. 
Therefore,  the  longer  this  flexed  position  has  been  maintained, 
the  more  marked  it  becomes,  as  is  the  case  in  paralysis  originat- 
ing in  the  nervous  centres.  Luecke  is  of  the  opinion  that,  in 
chronic  joint  disease,  the  flexed  position  of  the  joint  is  adopted 
voluntarily  or  from  expediency,  so  as  to  facilitate  the  use  of  the 
limb,  in  the  same  manner  as  scolio-lordosis  is  adopted  to  com- 
pensate adduction,  disappearing  when  the  patient  is  confined  to 
bed,  as  its  only  purpose  is  to  avoid  limping.  The  posture  is 
further  influenced  by  the  destruction  of  integral  parts  of  the 
joints ;  adduction  in  the  hip,  for  instance,  is  caused  by  destruc- 
tion of  the  acetabulum,  in  the  same  manner  as  the  varus  position 
of  the  knee  is  due  to  destructive  changes  affecting  the  internal 
condyle  of  the  femur  or  the  inner  tuberosity  of  the  tibia. 

Remak  ("Contractor   bei    Tuberkulose."     Berliner   klin. 


SYMPTOMS   AND    DIAGNOSIS. 


171 


Woclienschrift,  B.  xxvii,  No.  15,  1890)  is  of  the  opinion  that 
contraction  of  muscles  in  tuberculosis  of  joints  is  the  consequence 
of  a  reflex  neurosis.  He  cites,  in  illustration  of  the  correctness 
of  his  position,  a  case  of  tuberculosis  of  the  shoulder-joint  in 
which  he  found  the  tendon-reflex  of  most  of  the  muscles  of  the 
shoulder  and  arm  greatly  increased,  but  not  so  the  mechanical 
irritability. 


FIG.  29.— EARLY  STAGE  OF 
COXITIS— SLIGHT  FLEXION  OF 
THIGH  AND  ROTATION  OF  LIMB 
OUTWARD.  (Sayre.) 


FIG.  30. —TYPICAL  APPEAR- 
ANCE OF  KNEE-JOINT,  CAUSED 
BY  LONG-STANDING  TUBERCULAR 
DISEASE  OF  THE  JOINT.  (8ayre.) 


There  can  be  but  little  doubt  that  this  factor  plays  an 
important  part  in  the  production  of  muscular  contractions  during 
the  early  stages  of  joint  disease,  and  that  the  structural  changes 
in  the  joint  which  occur  later,  and  which  determine  fixation  of 
the  joint  in  malposition,  are  due,  at  least  in  part,  to  the 
increased  intra-articular  pressure  and  destruction  of  tissue  result- 
ing from  the  prolonged  muscular,  contractions  and  the  inflam- 
matory process. 


172  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

Shortening  of  Limb. — The  impression  has  prevailed  for  a 
long  time  that  the  shortening  of  a  limb  affected  by  tubercular 
joint  disease  is  caused  almost  exclusively  by  destructive  changes 
in  the  articular  extremities,  but  Julius  Wolff  ("Ueber  trophische 
Storungen  bei  primaren  Gelenkleiden."  Berliner  Idin.  Wochen- 
schrift,  Nos.  28,  29,  30,  1887)  has  shown  that  the  extent  of  loss 
of  substance  does  not  always  determine  the  degree  of  shortening. 
He  has  made  the  observation  that,  in  some  instances,  the 
affected  limb  is  actually  elongated.  He  attributes  the  shorten- 
ing largely  to  a  tropho-neurotic  affection  in  connection  with 
joint  disease,  which  brings  about  a  diminution  in  thickness  and 
length  of  the  bones  of  the  affected  limb.  The  same  view  is 
entertained  by  Valtat  and  Remak.  Analogous  conditions  of  the 
bones  are  met  with  in  infantile  paralysis  and  progressive  mus- 
cular atrophy  (Friedreich,  Volkmann).  Whether  the  atrophy 
of  the  bones  is  due  to  a  secondary  neuritis  or  follows  in  conse- 
quence of  a  reflex  action  of  the  trophic  centres  in  the  spinal 
cord  Wolff  is  unable  to  decide,  but  is  inclined  to  support  the 
latter  theory,  which  is  the  one  so  generally  supported  by  French 
authors. 

Dislocation  and  Other  Deformities  of  Joint. — Contraction, 
rotation,  lateral  deviations,  subluxations,  and  other  abnormal 
positions  usually  indicate  more  or  less  destruction  of  the  articular 
surfaces  of  the  bones  and  structural  changes  of  the  ligaments. 
These  malpositions  are  not  seen  in  articular  hydrops  or  the 
milder  forms  of  synovial  tuberculosis,  while  we  find  different 
degrees  of  one  or  more  of  them  in  nearly  every  case  of  advanced 
fungous  synovitis.  In  advanced  cases  of  synovial  tuberculosis 
of  the  knee-joint  the  joint  is  flexed,  the  leg  rotated  outward,  and 
the  head  of  the  tibia  displaced  backward.  In  the  hip-joint  the 
disease  gives  rise  to  flexion  of  the  thigh  upon  the  pelvis,  and  at 
first  e version  but  later  inversion  of  the  limb.  After  separation 
of  the  head  of  the  femur,  or  extensive  destruction  of  the  articular 
end  of  this  bone  and  the  acetabulum,  the  contour  of  the  region 
of  the  hip-joint  and  the  position  of  the  limb  simulate  dislocation 


SYMPTOMS   AND   DIAGNOSIS.  173 

of  the  head  of  the  femur  upon  the  dorsum  of  the  ilium  or 
fracture  through  the  neck  of  this  bone.  Tubercular  disease  of 
the  elbow-joint  gives  rise  to  flexion  and  pro  nation  of  the  fore- 
arm. The  clinical  importance  of  any  of  these  displacements 
lies  in  the  fact  that  they  signify  a  certain  amount  of  destruction 
of  the  joint  structures,  thus  often  indicating  surgical  interference 
for  the  correction  of  the  deformity,  as  well  as  the  removal  of  the 
diseased  tissue.  Complete  and  partial  dislocations,  occurring  in 
consequence  of  tubercular  arthritis,  have  given  rise  to  a  great 
deal  of  discussion  in  regard  to  the  nature  of  the  pathological 
conditions  which  produce  them  and  the  extent  of  the  displace- 
ment. Sonnenburg  ("Die  spontanen  Luxationen  des  Knie- 
gelenks."  Deutsche  Zeitschrift  f.  Chirurgie,  B.  xli)  has  found 
that  in  some  cases  of  apparent  dislocation  of  the  tibia  backward, 
in  chronic  inflammation  of  the  knee-joint,  there  is  no  displace- 
ment of  the  articular  surfaces,  but  the  deformity  is  caused 
by  a  bending  of  the  tibia  at  the  upper  epiphysial  line,  which 
gives  rise  to  an  appearance  of  the  joint  which  closely  resembles 
a  partial  dislocation  of  the  head  of  the  tibia  backward.  In 
adults  the  same  condition  can  follow  osteoporosis  of  the  upper 
end  of  the  tibia.  This  deformity  is  prone  to  occur  in  persons 
confined  to  bed  for  a  long  time  with  disease  of  the  knee-joint ; 
when  the  leg  is  so  placed  that  it  rests  its  weight  at  a  point  some 
distance  below  the  knee-joint  this  support  acts  as  a  fulcrum  and 
transforms  the  tibia  into  a  lever.  In  persons  who  use  the  limb 
this  partial  infraction  may  occur  in  consequence  of  the  peculiar 
manner  in  which  the  patient  rests  the  weight  of  the  body  on 
the  diseased  limb  in  walking.  Usually,  however,  the  deformity 
which  attends  fungous  synovitis  is  caused  either  by  muscular 
contraction,  faulty  position  of  the  limb,  or  destruction  of  the 
soft  and  bony  structures  of  the  joint,  or  follows  the  effect  of  the 
action  of  two  or  all  of  these  causes  combined. 

Pain. — Pain,  as  a  symptom  accompanying  tuberculosis  of 
joints,  although  always  present,  is  of  extremely  variable  inten- 
sity. If  the  diseased  part  is  in  such  a  location  that  it  is  pro- 


174  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

tected  from  injury,  and  perfect  rest  can  be  secured,  it  is  so  slight 
that  this  symptom  is  often  overlooked  by  patients,  even  in  cases 
where  the  disease  has  arrived  at  an  advanced  stage.  In  some 
cases  of  primary  synovial  tuberculosis  it  is  so  slight  that  patients 
will  continue  to  use  joints  distended  with  masses  of  fungous 
granulations  without  much  suffering,  while  in  other  instances 
a  limited  disease  in  the  joint  will  cause  complete  disability  and 
a  great  deal  of  suffering.  According  to  my  observation,  the 
pain  is  usually  more  severe  in  cases  where  the  granulations 
are  scanty  than  when  the  synovial  membrane  is  the  seat 
of  extensive  fungosities.  As  a  point  in  differential  diagnosis, 
it  may  be  said  that,  in  osseous  tuberculosis,  pain  is  present 
from  the  beginning  in  the  bone,  and  is  not  much  aggravated 
if  the  primary  disease  in  the  bone  is  followed  by  a  secondary 
affection  of  the  adjacent  joint ;  while  an  almost  painless  primary 
synovial  tuberculosis  is  followed  by  severe  pain,  with  nocturnal 
exacerbations,  as  soon  as  the  synovial  membrane  and  articular 
cartilages  have  been  destroyed  and  the  bone  has  been  second- 
arily implicated  in  the  inflammatory  process.  Absence  of 
tenderness  away  from  the  joint  would  indicate  rather  a  primary 
synovial  tuberculosis  than  the  osseous  variety.  In  primary 
synovial  tuberculosis  of  the  hip-joint  the  pain  is  located  in  the 
joint  and  groin  ;  while  in  the  osseous  form,  during  the  early 
stage,  at  least,  it  is  usually  referred  to  the  inner  aspect  of 
the  knee. 

Differential  Diagnosis. — Remembering  the  frequency  of 
tuberculosis  of  joints  as  compared  with  affections  due  to  other 
causes,  as  a  rule,  there  is  little  difficulty  in  their  recognition  if 
the  history,  course,  and  symptoms  are  carefully  studied  and  ana- 
lyzed. Konig  justly  remarks  that  it  is  well  to  remember  that 
articular  tuberculosis,  even  if  the  disease  affect  a  large  joint,  is 
practically  a  local  disease,  and  has  for  a  long  time  little  or  no 
influence  on  the  general  health  of  the  patient.  Thus,  we  may 
find  patients  presenting  all  the  appearances  of  robust  health 
suffering  from  extensive  articular  tuberculosis. 


SYMPTOMS   AND   DIAGNOSIS.  175 

The  tubercular  hydrops  is  distinguished  from  a  catarrhal 
or  rheumatic  synovitis  with  copious  effusion  by  its  persistency 
and  tendency  to  return  after  aspiration  or  after  active  use  of  the 
joint.  The  presence  of  flocculi  or  rice-bodies  in  a  joint  con- 
firms the  tubercular  nature  of  the  affection.  A  tuberous  syno- 
vitis, with  the  formation  of  a  single  mass  of  tubercular  tissue, 
sessile  or  pedunculated,  might  be  mistaken  for  lipoma  arbo- 
rescens  or  gnmmata.  The  diagnosis  of  the  latter  will  be  cleared 
up  by  a  course  of  antisyphilitic  treatment,  which  should  always 
be  instituted  in  cases  of  doubt.  Tubercular  joint-abscess  is  dis- 
tinguished from  suppurative,  gonorrhoea!,  or  rheumatic  synovitis 
by  the  pain  being  less  and  the  absence  of  all  signs  of  acute 
inflammation.  The  local  conditions  in  fungous  synovitis  are  so 
characteristic  that  they  can  hardly  be  misinterpreted  by  a  care- 
ful observer.  The  presence  or  absence  of  fluid  in  the  joint  has 
often  to  be  determined  by  an  exploratory  puncture.  The  caries 
sicca  of  Volkmann,  or  dry,  pannous,  hyperplastic  synovitis  of 
Hueter,  especially  as  found  in  the  shoulder-joint,  might  be  mis- 
taken for  a  neurosis,  with  atrophy  of  the  muscles  covering  the 
joint.  The  differential  diagnosis  can  be  made  by  examining 
the  patient  when  fully  under  the  influence  of  an  anaesthetic. 
If  the  affection  is  a  neurosis,  motion  will  be  found  unimpaired ; 
if  it  is  tubercular,  the  mobility  of  the  joint  will  be  found  les- 
sened by  infra-articular  adhesions  and  cicatricial  contraction  of 
the  capsule  of  the  joint.  It  is  necessary  under  this  heading 
to  discuss  somewhat  more  fully  the  important  points  in  differ- 
ential diagnosis  of  a  few  affections  of  the  joints  which  are  most 
likely  to  be  mistaken  for  tuberculosis,  and  vice  versd. 

Rheumatic  Arthritis.-^- Acute  rheumatism  appears  clinically 
as  a  poly-articular  affection.  The  essential  cause  of  this  disease 
very  frequently  attacks  at  the  same  time  the  heart-muscle  and 
the  endocardium  and  pericardium.  It  is  a  febrile  affection,  and 
often  disappears  after  a  few  weeks  without  medical  interference. 
Subacute  rheumatic  arthritis  involves  the  synovial  membrane, 
capsule  of  joint,  and  para-articular  fibrous  structures ;  the  in- 


176  TUBERCULOSIS    OF    THE   BONES   AND   JOINTS. 

flammatory  product  consists  of  a  plastic  exudation,  the  removal 
of  which  proves  exceedingly  obstinate  to  all  known  methods  of 
treatment.  In  the  chronic  variety  the  disease  may  be  limited 
to  a  single  joint;  but  more  frequently  a  number  of  joints  are 
affected  simultaneously  or  in  succession.  This  disease  resembles 
tubercular  arthritis  more  closely  than  the  acute  and  subacute 
varieties,  in  that  it  attacks  not  only  the  synovial  membrane  and 
capsule  of  the  joint,  but  not  infrequently  extends  to  the  articu- 
lar extremities  of  the  bones,  giving  rise  to  a  complexus  of 
symptoms  which  closely  resembles  caries  sicca. 

Syphilitic  Arthritis. — In  syphilitic  joint  affections  occur- 
ring as  one  of  the  manifestations  of  the  subacute  form  of  syph- 
ilis during  the  second  stage,  the  synovial  membrane,  para-artic- 
ular tissues,  or  periosteum  are  affected.  In  the  tertiary  form  of 
the  disease  gummata  develop  in  the  subsynovial  tissues  or  peri- 
osteum. The  syphilitic  joint  affections,  during  the  second  stage, 
are  different  from  the  rheumatic,  in  so  far  that  the  fever  attend- 
ing the  former  shows  marked  paroxysmal  exacerbations  toward 
evening ;  at  the  same  time  involvement  of  the  lymphatic  glands 
and  other  luetic  symptoms  are  present.  In  the  tertiary  form 
the  joint  and  bone  affections  have  the  peculiarity  that  the  affec- 
tions develop  slowly,  and  the  separate  gummata  appear  as  cir- 
cumscribed indurations.  If  any  doubt  remain  as  to  the  nature 
of  the  joint  affection  between  syphilis  and  tuberculosis,  this  can 
be  readily  dispelled  in  a  few  weeks  by  placing  the  patient  under 
an  energetic  antisyphilitic  treatment.  Gillette  ("  Diseases  of 
the  Hip-Joint."  Medical  News,  July  11,  1891)  relates  a  very 
interesting  case  of  syphilitic  coxitis  in  a  child  7  years  old. 
There  was  apparent  lengthening,  but  actual  shortening; 
atrophy  of  limb,  but  only  slight  tenderness;  limb  abducted 
and  slightly  flexed.  The  mother  gave  a  history  of  the  patient 
having  had  a  similar  attack  four  years  previously.  At  that 
time  the  joint  was  very  painful,  and  was  treated  by  immobiliza- 
tion in  a  plaster-of-Paris  dressing.  As  the  child  presented  a 
suspicious  eruption,  antisyphilitic  treatment  was  instituted, 


PLATE  VI, 


FIG.    3J. — ACROMEGALIA   (?).      OSTEITIS  DEFORMAN6.      (Marie.) 


SYMPTOMS   AND    DIAGNOSIS.  177 

which  resulted  in  a  complete  recovery.  The  second  attack 
resembled  a  typical  tubercular  coxitis.  The  usual  treatment  by 
rest  in  bed  and  extension  proved  of  no  avail.  A  well-marked 
syphilitic  eruption  again  suggested  a  syphilitic  cause,  and  a 
short  course  of  specific  treatment  resulted  again  in  a  speedy 
and  perfect  cure. 

Osteitis  Deformans. — Osteitis  deformans,  as  it  usually  pre- 
sents itself,  is  recognized  without  much  difficulty,  and  is  not 
likely  to  be  mistaken  for  joint  or  bone  tuberculosis.  When 
the  disease  affects  the  spine,  the  kyphosis  resembles  the  curva- 
ture in  cases  of  tubercular  spondylitis  when  a  number  of  ver- 
tebrae are  affected  at  the  same  time.  Marie  describes  such  a 
case  as  acromegalia ;  but  Virchow  regarded  it  as  a  case  of 
osteitis  deformans.  (Plate  VI,  Fig.  31.) 

Typhoid  Arthritis. — A  number  of  acute  infectious  diseases 
— notably  typhoid  fever — are  followed,  within  a  few  days  to  sev- 
eral weeks  after  convalescence  has  been  apparently  established, 
by  a  non-suppurative  destructive  joint  affection,  which,  in  many 
respects,  resembles  tubercular  arthritis,  and  which  it  is  often 
very  difficult  to  distinguish  from  the  latter  affection. 

Gibney  {Transactions  American  Orthopaedic  Association, 
vol.  ii),  in  an  article  on  "  Typhoid  Spine,"  reports  cases  of  dis- 
ease of  the  hip-joint  which  bear  a  close  resemblance  to  tubercu- 
losis of  this  joint.  One  was  that  of  a  young  lady,  18  years 
old,  convalescing  from  typho-malarial  fever  and  suffering  with 
acute  pain  in  the  hip.  Any  movement  of  the  limb  would 
excite  severe  pain.  Extension  afforded  relief  in  less  than  a 
month.  Almost  complete  recovery  followed  in  a  few  months. 
Gibney  regarded  this  case,  from  a  pathological  stand-point, 
as  a  para-articular  lesion  confined  to  the  periosteum  or  liga- 
ments. Another  case  was  that  of  a  boy  aged  13.  Four  or  five 
months  after  an  attack  of  typhoid  fever,  while  confined  to  his 
bed,  he  kept  both  limbs  flexed,  and  during  convalescence  was 
unable  to  straighten  them.  The  thighs  were  sharply  flexed 
on  the  pelvis,  the  legs  on  the  thighs,  the  heels  touching  the 


178  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

buttocks.  Any  attempt  at  motion  of  the  right  thigh  caused 
reflex  spasm. 

Sarcoma  of  Joints. — This  affection  is  exceedingly  rare,  and 
on  this  account  it  would  most  likely  be  mistaken  for  tubercu- 
losis unless  special  attention  were  given  to  differential  diagnosis 
between  these  two  affections.  Garre  reports  an  interesting  and 
rare  case  of  diffuse  sarcoma  of  the  synovial  membrane  and  liga- 
mentous  structures  of  the  knee-joint.  (Beit rage  zur  Minischen 
Chirurgie,  B.  vii,  Heft  1.)  A  woman,  aged  34,  died  one  month 
after  amputation  through  the  thigh,  and,  on  post-mortem  exam- 
ination, large  and  widely-diffused  secondary  deposits  were  found 
in  almost  every  organ  of  the  body.  The  diagnosis  of  the  nature 
of  the  disease  in  this  case  was  at  first  attended  with  some  doubt, 
as  the  swollen  and  pulpy  condition  of  the  affected  joint  sug- 
gested tuberculosis.  Microscopical  examination  after  amputa- 
tion showed  it  to  be  a  diffused,  round-celled  sarcoma  of  the  cap- 
sule of  the  knee-joint,  with  medullary  sarcoma  of  the  lower  end 
cf  the  fvMiur;.  The  author  is  of  the  opinion  that  the  tumor 
started  primarily  in  the  soft  structures  of  the  joint,  and  not  in  the 
bone.  The  soft  structures  of  the  joint  had  been  converted  into 
a  mass  of  very  thick  and  firm  tissue,  and  the  disease  had  been 
so  nui Hi  diffused  as  to  surround  and  compress  the  popliteal  ves- 
sels. Before  the  amputation  the  temperature  taken  in  the  rectum 
had  been  irregular  and  at  times  high.  According  to  Garre,  in- 
explicable elevations  of  temperature  at  irregular  intervals  fre- 
quently occur  in  cases  of  sarcoma  of  bone.  The  constitutional 
disturbances  were?,  it  is  stated,  much  more  intense  in  this  case 
than  those  usually  present  in  cases  of  localized  tubercular  lesion. 

Popliteal  Cysts. — In  the  differential  diagnosis  between 
chronic  affections  of  the  knee-joint  and  its  immediate  vicinity, 
it  is  necessary  to  call  special  attention  to  the  subject  of  popliteal 
cysts.  After  post-mortem  examination  of  over  a  thousand  knee- 
joints,  and  after  clinical  observations  of  upward  of  a  hundred 
patients  suffering  from  cysts  about  the  knee,  Poirier  (Le  Prog- 
res  Medical,  vol.  xii,  No.  43)  came  to  the  conclusion  that  pop- 


SYMPTOMS   AND    DIAGNOSIS.  179 

liteal  cysts,  even  those  which  occupy  the  portion  of  the  bursse, 
are  nearly  all  of  articular  origin.  Of  one  hundred  cases  sub- 
jected to  most  rigid  examination,  not  one  was  found  which  had 
not  a  distinct  articular  origin.  The  most  frequent  variety  of 
popliteal  cysts  is  that  which  is  found  external  to  the  tendon  of 
the  semimembranosus  in  the  popliteal  flexure.  It  is  very  promi- 
nent when  the  leg  is  extended,  but  seems  to  disappear  on  flexion. 
It  implicates  the  bursa  placed  between  the  tendon  of  this  muscle 
and  the  internal  condyle.  This  bursa  is,  however,  in  closer  rela- 
tion to  the  cavity  of  the  joint  than  any  of  the  other  bursae,  and 
often  communicates  with  it  directly.  Another  form  of  cyst,  not  so 
frequently  recognized,  is  that  due  to  the  outgrowth  of  the  synovial 
membrane  of  the  joint.  It  involves  the  bursa  beneath  the  pop- 
liteus,  and  appears  as  a  deep-seated  swelling  in  the  upper  portion 
of  the  calf.  A  third  variety  of  popliteal  cysts  is  that  which  ap- 
pears in  the  upper  portion  of  the  condyloid  region.  The  bursa 
placed  above  the  internal  condyle  is  usually  a  prolongation  of  the 
synovial  lining  of  the  joint.  Finally,  cysts  may  appear  in  any 
part  of  the  joint,  presenting  the  features  of  ganglion,  but  really 
due  to  the  development  of  subsynovial  cysts  or  to  synovial  hernia. 
Echinococcus. — As  an  extremely  rare  chronic  joint  affec- 
tion, which  might  be  confused  with  tuberculosis,  must  be  men- 
tioned echinococcus.  Fischer  {Deutsche  Zeitschrift  f.  Cliirurgie, 
1891,  Nos.  1  and  2)  has  reported  the  case  of  a  man  44  years 
old,  in  which,  following  an  injury  of  the  lower  end  of  the  left 
thigh,  great  pain,  swelling,  and  fluctuation  appeared  at  the 
knee-joint.  An  incision  above  and  internal  to  the  patella  evacu- 
ated a  considerable  quantity  of  a  thin,  nearly  clear  fluid,  with 
about  a  dozen  echinococcus  cysts.  Swelling  and  fluctuation, 
however,  returned.  The  knee-joint  was  then  exposed,  and  many 
echinococcus  cysts,  with  serous  fluid,  were  evacuated.  The  vas- 
cular synovial  membrane  and  the  suspected  parts  of  the  capsule 
of  the  joint  were  extirpated  and  the  lower  end  of  the  femur 
thoroughly  cleansed ;  complete  recovery  ensued,  with  scarcely 
any  impairment  of  the  usefulness  of  the  joint. 


CHAPTER  XVIII. 

PROGNOSIS. 

A  PERSON  who  has  once  been  the  subject  of  a  tubercular 
affection  of  a  joint  is  always  in  danger  of  suffering  from  a  local 
recurrence  or  tuberculosis  in  some  other  organ.  Even  the  most 
thorough  operation  cannot  afford  absolute  protection  against 
local  relapse  or  distant  tuberculosis.  For  many  years  Konig 
has  taught  most  emphatically  that  a  tubercular  affection  of 
bones  and  joints  is  only  a  peripheral  manifestation  of  the  exist- 
ence of  other  tubercular  affections,  and  that  it  is  never  met  with 
etiologically  as  a  primary  lesion.  If  this  is  the  case,  and  his 
position  has  been  well  supported  by  clinical  facts,  it  is  evident 
that  complete  local  eradication  of  the  bone  or  joint  disease  by 
operative  measures  might  prove  successful  in  preventing  re-in- 
fection from  the  existing  peripheral  lesion,  but  all  known  efforts 
would  prove  futile  in  affecting  a  permanent  cure,  as  hidden  and 
inaccessible  foci  which  caused  the  bone  or  joint  affection  may  at 
any  time  become  again  a  distributing  point  of  the  essential  cause 
of  the  disease, — the  bacilli  of  tuberculosis.  In  not  an  inconsider- 
able number  of  cases  of  peripheral  recognizable  tuberculosis, 
patients  are  already  the  victims  of  tubercular  affections  of  one 
or  more  of  the  internal  organs,  notably  the  lungs.  In  two 
hundred  and  fifty-eight  cases  collected  and  studied  by  Thiery 
witli  special  reference  to  this  point,  he  found  in  sixty-three  well- 
marked  evidences  of  pulmonary  tuberculosis ;  in  seventy-two  no 
signs  of  pulmonary  lesion,  and  no  reference  to  this  condition  in 
one  hundred  and  twenty-three. 

In  tuberculosis  of  the  vertebrae  the  same  author  found  one 
out  of  six  cases  affected  at  the  same  time  with  visceral  tubercu- 
losis. Aside  of  the  constant  danger,  owing  to  the  existence  of 
additional  inaccessible  foci,  it  is  impossible  to  foretell  at  what 
time  re-infection  may  take  place  from  a  tubercular  joint.  In 
order  to  determine  the  time  at  which  a  local  focus  gives  rise  to 
(180) 


PROGNOSIS.  181 

local  and  general  infection,  Jeannel  ("Nouvelles  recherches  ex- 
peri  men  tales  sur  la  tuberculose  et  sa  curabilite."  fitude  sur  hi 
tuberculose,  p.  416)  inoculated  seventeen  rabbits  in  the  left  ear 
with  material  taken  from  a  tubercular  cow.  The  ear  of  each 
of  these  animals  was  cut  off  three  to  four  centimetres  from  the 
point  of  inoculation  at  intervals  of  twenty-four  hours,  and  the 
specimens  representing  inoculations  from  twenty-four  hours  to 
seventeen  days  were  carefully  examined.  Ten  of  the  rabbits 
died  of  tuberculosis.  The  animals  that  lost  the  inoculated  ear 
during  the  first  four  days  presented  well-marked  tubercular 
lesions.  In  a  second  series  of  experiments  conducted  in  the 
same  manner,  four  of  the  rabbits  were  tubercular  and  six  had 
escaped  the  disease,  and  in  a  third  series  all  of  the  rabbits  were 
found  to  be  tubercular.  From  these  experiments  the  author 
comes  to  the  formidable  conclusion  that,  after  subcutaneous  in- 
oculation with  tubercular  material  in  rabbits  the  disease  has 
ceased  to  be  local  in  twenty-four  hours,  and  that  generalization 
may  take  place  in  a  few  hours  after  inoculation.  In  all  of  the 
animals  in  which  the  inoculated  ear  was  amputated  within  ten 
minutes  after  inoculation,  no  local  or  general  tuberculosis  was 
observed,  but  when  the  time  was  extended  beyond  this  the 
animals  became  tubercular.  Although  the  results  of  these  ex- 
periments are,  of  course,  not  applicable  to  man,  they  teach  the 
surgeon  at  least  an  important  lesson  in  that  a  local  tubercular 
focus  at  any  time  may  become  the  centre  of  a  regional  and 
general  infection,  and  that  its  removal  before  this  has  oc- 
curred protects  the  organism  against  re-infection  from  this 
source.  At  the  same  time  it  should  not  .be  forgotten  that  the 
removal  of  a  peripheral  tubercular  lesion  has  often  a  curative 
effect  on  similar  internal  lesions  which  can  only  be  attributed 
to  suppression  of  re-infection  from  the  peripheral  focus.  Among 
the  cases  in  which  operative  treatment  under  such  circumstances 
gave  the  most  happy  results  is  one  related  by  le  Fort  in  his 
clinique,  December  20,  1888.  He  amputated  the  right  arm 
and  thigh  for  tubercular  affections  in  a  patient  who  was  suffer- 


182  TUBERCULOSIS  OF   THE   BONES   AND   JOINTS. 

ing  at  the  same  time  from  pulmonary  phthisis.  The  patient's 
general  condition  improved,  and  the  bacilli  in  the  sputum  be- 
came much  less  in  number.  The  improvement  continued  steadily 
for  a  long  time,  and  was  in  progress  when  the  report  was  made, 
when  he  was  still  an  inmate  at  the  Bicetre.  At  the  same  time 
le  Fort  cited  the  history  of  another  case,  where  the  patient  had 
already  submitted  to  several  amputations,  and  for  whom  he 
proposed  to  amputate  the  forearm  for  a  new  tumor  albus.  This 
patient  was  free  from  pulmonary  tuberculosis,  and  recovered  his 
usual  health  and  weight  after  amputation.  Post-operative  re- 
sults are  sometimes  most  favorable  in  previously  tubercular 
patients,  instances  of  which  are  reported  by  Thiery.  In  one 
case  the  patient  was  suffering  from  osteo-arthritis  of  foot ;  at  the 
same  time  he  coughed  up  bloody  sputa.  Amputation  of  leg; 
healing  of  wound  delayed  by  imperfect  suturing ;  general  health 
improved  promptly.  In  another  somewhat  similar  case  the 
general  condition  was  very  precarious  before  supra-malleolar 
amputation  was  made  for  tuberculosis  of  ankle;  primary  heal- 
ing of  wound  and  recovery  of  former  weight  and  health. 
Similar  instances  have  repeatedly  come  under  my  personal  ob- 
servation and  could  be  indefinitely  multiplied  by  cases  from  the 
general  surgical  literature,  but  enough  has  been  said  to  show 
the  value  of  efficient  surgical  treatment  in  peripheral  tubercu- 
losis, even  if  one  or  more  of  the  internal  organs  are  similarly 
affected.  One  of  the  sources  of  danger  in  chronic  tuberculosis 
is  fatty  degeneration  of  the  liver. 

Louis  and  Andral  called  attention  to  the  fact  that  fatty 
degeneration  of  this  organ  is  met  with  more  frequently  in  tuber- 
culosis than  any  other  disease.  The  degeneration  commences 
around  the  tubercles  and  around  the  portal  spaces,  as  if  the 
tubercles  and  the  contents  of  the  ramifications  of  the  portal 
vein  exercised  directly  a  steatogenic  action  on  the  contiguous 
hepatic  cells.  Tuberculosis  of  a  joint  may  terminate  in  a  spon- 
taneous cure  in  cases  in  which  the  intensity  of  the  infection  is 
slight,  or  the  resistance  on  the  part  of  the  patient  is  so  great  that 


PROGNOSIS.  183 

the  fungous  granulations  do  not  undergo  degenerative  changes, 
but  are  converted  into  permanent  connective  tissue.  A  partial 
or  complete  synechia  of  the  cavity  of  a  tubercular  joint  is  often 
one  of  the  unavoidable  results  in  such  cases,  leaving  the  joint 
in  a  permanently  stiff  condition.  This  endeavor  on  the  part 
of  the  organism  to  limit  the  extension  of  the  disease  is  often 
observed  in  cases  in  which  the  joint  affection  occurs  in  con- 
nection with  osseous  tuberculosis.  As  soon  as  perforation  of  a 
focus  into  a  joint  has  occurred  a  wall  of  granulation  tissue  is 
thrown  out  around  the  circumscribed  area  of  infection,  and, 
under  favorable  circumstances,  a  partition  of  cicatricial  tissue  is 
formed  which  isolates  the  infected  area  from  tho  intact  portion 
of  the  joint.  In  such  instances  we  have  an  illustration  how  the 
tubercular  process  is  retarded,  and  sometimes  permanently 
arrested,  by  the  transformation  of  granulation  into  connective 
tissue.  For  such  a  favorable  termination  to  take  place,  it  is 
necessary  that  the  tubercular  virus  should  be  attenuated  by  age 
or  a  want  of  proper  nutrient  medium,  or  that  the  pathogenic 
effect  of  the  bacilli  should  be  neutralized  by  a:i  adequate  resist- 
ance on  the  part  of  the  tissues  before  degenerative  changes  have 
occurred  in  the  granulation  tissue.  The  course  of  articular 
tuberculosis  is  so  variable  in  different  cases  that  it  is  inriossiblr1, 
during  the  early  stages  of  an  attack,  to  predict  anything  certain 
in  reference  to  the  probable  final  outcome.  A  spontaneous  cure 
is  more  likely  to  take  place  if  the  patient  is  young,  not  ansemio, 
and  at  the  same  time  well  nourished.  The  hygienic  surround- 
ings must  also  be  taken  into  consideration  in  rendering  a  prog- 
nosis. The  hereditary  is  more  grave  than  the  acquired  form. 
The  disease  shows  greater  tendencies  to  limitation  in  children 
than  in  persons  past  the  age  of  puberty.  Among  the  different 
pathological  varieties  of  joint  tuberculosis,  the  tubercular  hydrops 
and  caries  sicca  are  the  most  benign,  and  in  these  cases  a  spon- 
taneous cure  is  most  frequently  realized,  and  the  same  conditions 
are  also  most  amenable  to  successful  surgical  treatment.  The 
caries  sicca  may,  according  to  Konig,  terminate  in  a  spontaneous 


184  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

cure  in  two  or  three  years,  with  some  loss  of  motion  in  the  joint. 
It  is  often  difficult  to  ascertain,  in  a  given  case,  when  the  lesion 
can  be  considered  as  cured.  As  the  most  reliable  evidences  that 
such  favorable  termination  has  taken  place  must  be  considered 
disappearance  of  swelling,  pain,  tenderness  and  restoration  of 
function  as  far  as  this  can  be  expected.  The  patient  should 
not  be  permitted  to  use  the  limb  until  the  active  symptoms  of 
inflammation  have  disappeared.  The  danger  to  life  arises  from 
the  existence  of  complications,  foremost  among  them  being 
septic  infection,  pulmonary  or  general  tuberculosis,  and  amyloid 
degeneration  of  important  internal  organs.  Septic  infection 
is  caused  either  by  localization  of  pus-microbes  brought  to  the 
tubercular  focus  through  the  circulating  blood,  or,  what  is  more 
frequently  the  case,  through  an  infection-atrium,  created  by  a 
spontaneous  opening  through  an  operation  wound,  an  explora- 
tory puncture,  or,  finally,  through  a  fistulous  communication 
with  the  joint.  Many  neglected  cases  of  joint  tuberculosis  die 
annually  of  pulmonary  or  general  tuberculosis.  Billroth  states 
that  in  sixteen  years  27  per  cent,  of  all  cases  of  bone  and  joint 
tuberculosis,  under  his  observation,  were  lost  in  this  way.  Konig, 
from  a  table  of  one  hundred  and  seventeen  operations  for  tuber- 
culosis, found  that  after  four  years  16  per  cent,  died  of  general 
tuberculosis.  If  a  patient  escape  death  from  septic  infection, 
after  secondary  infection  with  pus-microbes,  he  is  liable  to 
succumb  several  years  later  to  amyloid  degeneration  of  important 
internal  organs,  the  spleen,  the  liver,  and  especially  the  kidneys, 
with  its  accompanying  anasarca.  The  prognosis  must  rest,  then, 
in  each  individual  case,  upon  the  age  of  the  patient,  the  location 
and  extent  of  the  disease,  the  general  condition  of  the  patient, 
and  the  presence  or  absence  of  complications. 


CHAPTER    XIX. 

TREATMENT  OF  TUBERCULOSIS  OF  JOINTS. 

General  Treatment. — The  successful  treatment  of  a  tuber- 
cular bone  or  joint  affection  requires  that  the  patient  should  re- 
ceive the  benefits  to  be  derived  from  both  local  and  general 
treatment.  The  surgeon  should  not  only  make  use  of  every 
local  resource  best  calculated  to  cure  or  remove  the  local  lesion, 
but  must  also  possess  and  apply  the  knowledge  and  skill  of  an 
intelligent  physician  in  the  treatment  of  such  cases.  The  neces- 
sity of  general  treatment,  hygienic,  climatic,  dietetic,  and  medical, 
must  become  apparent,  if,  as  has  been  shown  by  clinical  expe-, 
rience  and  post-mortem  examinations,  that  the  local  affection  in 
the  bone  or  joint  is,  in  the  great  majority  of  cases,  but  a  mani- 
festation of  the  existence  of  a  tubercular  focus  in  another  and 
perhaps  inaccessible  part  of  the  body,  A  failure  on  the  part  of 
the  surgeon  to  institute  and  carry  out  a  rational  course  of  gen- 
eral treatment  would  be  as  detrimental  to  the  patient  as  a  sole 
reliance  upon  it  in  curing  the  local  affection.  Both  extremes  are 
equally  dangerous,  and  should  be  carefully  avoided.  Although 
it  is  a  familiar  fact  that  tubercular  affections  of  bones  and  joints 
manifest  an  intrinsic  tendency  to  progressive  aggravation  by 
local  extension  and  systemic  re-infection,  cases  of  spontaneous 
cure  under  favorable  conditions  are  by  no  means  rare.  It  may 
be  laid  down  as  a  general  rule  that  whatever  contributes  toivard 
the  improvement  of  the  general  health  of  the  patient  retards  the 
progress  of  the  local  lesion  and  brings  about  the  most  favorable 
conditions  for  a  spontaneous  cure,  and  at  the  same  time  greatly 
adds  to  the  success  of  operative  treatment. 

Hygienic. — Hygienic  treatment  should  not  only  be  made 
use  of  as  a  curative  agent  in  the  treatment  of  tubercular  disease 
of  bones  and  joints,  but  is  equally  important  as  a  prophylactic 
measure.  Children  born  of  tubercular  parents  should  be  sur- 
rounded by  the  most  favorable  hygienic  conditions  from  the 

(185) 


186  TUBERCULOSIS   OF   THE    BONES   AND   JOINTS. 

time  of  birth  until  they  reach  the  age  of  puberty,  as  the  foun- 
dation for  tubercular  disease  is  usually  laid  during  the  period 
of  growth  and  development  of  the  skeleton.  They  should  be 
carefully  protected  against  inoculation  with  tubercular  sputum, 
and  all  surface  lesions,  large  and  small,  must  receive  careful  atten- 
tion in  order  to  prevent  the  formation  of  an  infection-atrium, 
through  which  tubercle  bacilli  might  enter  the  general  circula- 
tion, and  from  there  become  deposited  in  one  or  more  of  the 
bones  and  joints.  There  can  be  but  little  doubt  that,  in  persons 
with  a  general  predisposition  to  tuberculosis,  primary  infection 
often  takes  place  during  infancy  and  childhood,  through  eczema- 
tous  skin  or  insignificant  traumatic  defects  of  this  structure.  In 
the  same  class  of  cases  infection  has  often  been  traced  to  the  use 
of  milk  from  tubercular  cows,  and  for  this  reason  milk  should 
not  be  given  as  an  article  of  food  unless  it  is  rendered  sterile  by 
prolonged  boiling.  Infection  through  the  respiratory  tract 
should  be  guarded  against  by  separating  the  child  as  much  as 
possible  from  tubercular  members  of  the  family,  and  by  pro- 
viding for  it  a  well-ventilated  room,  and  by  giving  it  the  benefit 
of  out-door  air  and  exercise.  Frequent  bathing,  preferably  in 
salt  water,  followed  by  vigorous  rubbing  of  the  skin  with  a 
coarse  bathing-towel,  is  of  great  value  in  maintaining  a  vigor- 
ous peripheral  circulation,  which  is  admirably  adapted  to  pre- 
vent a  passive  hypersemia  in  the  parts  anatomically  predisposed 
to  the  localization  of  tubercle  bacilli,  and  thus  eliminate  an  in- 
direct cause  of  tubercular  affections  of  the  bones  and  joints. 
Sudden  chilling  of  the  external  surface  of  the  body  with  its 
concomitant  result,  suppression  of  the  cutaneous  secretions, 
which  is  so  often  mentioned  by  patients  as  the  immediate  cause 
which  precipitated  an  attack  of  bone  or  joint  disease,  must  be 
prevented  as  far  as  possible  by  protecting  the  skin  with  flannel 
under-clothing,  which  should  give  way  to  silk  or  cotton  only 
during  the  hot  summer  months.  An  abundance  of  nitrogenous 
food,  adapted  to  the  age  of  the  patient,  is  an  important  element 
in  the  prophylaxis  and  treatment  of  tuberculosis  of  bones  and 


TREATMENT  OF  TUBERCULOSIS  OF  JOINTS.         187 

joints.  A  well-selected  diet  is  of  the  utmost  importance  in  main- 
taining nutrition  and  a  normal  quantitative  and  qualitative 
blood-supply, — conditions  which  are  best  calculated  to  prevent 
localization  of  floating  tubercle  bacilli  in  the  bones  and  joints,  as 
well  as  in  other  organs,  and  to  check  extension  of  the  disease 
after  it  has  become  developed.  Milk,  cream,  eggs,  oysters,  raw  or 
rare  roast  meats,  with  a  liberal  allowance  of  fruit,  are  the  articles 
of  food  best  adapted  to  fulfill  these  indications.  As  regards  food, 
Bidder  ("  Ueber  zuwartende  u.  thiitig  eingreifende  Behand- 
lungsweisen  der  Gelenktuberculose."  .DeutscJte  Zeitsclirift  f. 
Chirurgie,  B.  xxi,  Heft  2,  p.  80),  in  speaking  of  the  treatment 
of  these  diseases,  lays  stress  on  the  avoidance  of  substances  rich 
in  potash,  and  also  of  starchy  materials,  and  strongly  advises 
the  employment  of  albuminous  foods  rich  in  soda  and  fat. 

A  probable  confirmation  of  this  view  is  the  noteworthy 
fact  that  tuberculosis  is,  as  a  rule,  very  common  in  herbivorous 
animals,  and  can  usually  be  readily  induced  in  them  artificially 
by  inoculation ;  while,  on  the  other  hand,  it  seldom  occurs 
spontaneously  in  the  carnivora,  and  these,  as  experiments  show, 
have  also  proved  more  refractory  to  inoculation,  feeding,  and 
inhalation  experiments.  Man,  who  subsists  on  a  mixed  diet, 
stands  midway  between  these  two  groups  in  his  susceptibility  to 
this  disease,  tuberculosis  being  more  often  local  and  less  virulent 
than  in  the  herbivora,  while  it  is  much  more  frequent  and  de- 
structive than  in  the  carnivora.  In  this  way  also  Bidder  ex- 
plains the  much  greater  frequency  of  tubercular  diseases  in  the 
western  part  of  Germany  than  in  the  eastern,  although  the 
density  of  the  population  is  greater  in  the  latter.  It  appears 
that  the  inhabitants  of  eastern  Germany  employ  less  vegetable 
diet  than  in  the  west,  and  eat  large  quantities  of  salt  meat.  Out- 
door exercise  should  be  insisted  upon  as  an  important  prophy- 
lactic measure  in  persons  predisposed  to  tuberculosis,  and  should 
be  advised  as  an  important  part  of  treatment  in  all  cases  in 
which  the  character  of  the  local  lesion  offers  no  contra-indica- 
tion.  A  change  of  residence  from  a  badly-ventilated  room  to 


188  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

one  supplied  with  an  abundance  of  fresh  air  and  sunshine,  or 
from  a  home  in  an  unhealthy  to  a  more  salubrious  part  of  a 
city,  or  from  an  overcrowded  city  into  the  country,  will  often 
prove  of  the  greatest  value,  both  as  a  prophylactic  and  curative 
aid. 

Change  of  Climate.  —  The  prophylactic  and  therapeutic 
value  of  change  of  climate  is  almost  universally  recognized  in  the 
treatment  of  pulmonary  tuberculosis.  This  method  of  treatment 
has  yielded  more  favorable  and  lasting  results  than  the  use  of 
drugs.  There  is  no  reason  why  the  same  treatment  should  not 
occasionally  effect  the  same  happy  results  in  cases  of  tubercu- 
losis of  bones  and  joints  if  the  affection  occupies  such  a  location, 
or  is  in  such  a  condition  as  to  justify  removal  of  the  patient. 
The  favorable  changes  wrought  by  a  change  of  climate  are  not 
always  owing  to  improved  climatic  influences,  but  are  very 
frequently  attributable  to  an  entire  change  of  surroundings, 
which  has  a  favorable  influence  in  securing  rest  and  in  improv- 
ing the  appetite.  A  few  weeks  or  months  at  the  sea-side  or  at 
some  mountain  resort  is  often  followed  by  a  marked  improve- 
ment of  the  local  affection  and  the  general  health  of  the  patient. 
For  patients  who  are  able  to  pay,  such  a  change  should  be  more 
frequently  prescribed  than  has  been  customary  heretofore  in 
this  country.  The  therapeutic  value  of  thermal  and  mineral 
baths  has  been  greatly  overestimated,  as  the  good  results  which 
have  been  obtained  by  sending  patients  to  such  health  resorts 
should  not  be  ascribed  so  much  to  the  therapeutic  action  of  the 
baths  as  to  the  change  of  climate  and  surroundings.  In  the 
selection  of  a  proper  climate  for  patients  suffering  from  bone  or 
joint  tuberculosis  a  locality  should  be  recommended  where  the 
patients  can  live  most  of  the  time  out-doors.  Patients  in  the 
North  should  spend  the  winter  months  in  the  South,  and  patients 
from  the  South  are  greatly  benefited  by  living  in  the  North  dur- 
ing the  summer  months.  The  same  care  should  be  exercised  in 
recommending  a  change  of  residence  to  the  sea-shore  or  to  a 
mountain  resort. 


TREATMENT   OF   TUBERCULOSIS   OF   JOINTS.  189 

Internal  Medication. — So  far  we  are  not  in  possession  of  a 
single  remedy  which  acts  as  a  specific  on  tubercular  tissue  as 
the  preparations  of  iodine  do  on  syphilitic  products.  The  drugs 
which  have  proved  most  useful  are  medicines  which  improve  the 
general  health.  Bitter  tonics  are  indicated  when  the  appetite  is 
poor,  some  preparation  of  iron  when  the  patient  is  anaemic,  and 
codliver-oil  and  its  substitutes  Avill  prove  beneficial  in  restoring 
flesh  and  strength  in  patients  with  unimpaired  digestion.  Cod- 
liver-oil  should  be  given  an  hour  and  a  half  after  meals,  and  in 
gradually  increasing  doses.  Moeller's  pale  oil  is  the  best,  and 
does  not  disturb  digestion  as  much  as  the  different  compounds 
of  oil,  iodine,  etc.,  and  the  various  emulsions  sold  at  more  than 
double  the  price  of  the  more  palatable  pure  oil.  Among  the 
preparations  of  iron,  the  iodide  deserves  special  mention.  It 
can  be  given  as  the  syrup  of  the  iodide  of  iron,  in  doses  of  from 
15  drops  to  a  teaspoonful  some  time  after  meals,  or  one  to  two 
Blan card's  pills  three  times  a  day.  At  one  time  Langenbeck 
("  Ueber  den  Einfluss  von  Aresenik  Behandlung  auf  Gelenk- 
tuberculose."  Deutsche  Med.  Wochenscrift,  B.  x,  p.  235)  had 
faith  in  the  administration  of  arsenic  in  the  treatment  of 
tubercular  affections  of  bones  and  joints,  and  recommended  its 
use  especially  in  the  after-treatment  after  resection.  I  have 
given  the  arsenic  treatment  a  fair  trial  in  different  forms  of 
surgical  tuberculosis,  either  with  negative  or  sometimes  harmful 
results.  Hofmokl  ("  Ueber  die  chirurgische  Behandlung  scroph- 
uloser  u.  tuberculoser  Leiden."  Wiener  Med.  Zeitung,  Novem- 
ber 22,  1889)  speaks  well  of  the  use  of  iodine,  but  I  have  never 
been  able  to  satisfy  myself  that  any  of  the  many  preparations 
of  this  drug  had  any  influence  in  arresting  or  otherwise  favor- 
ably influencing  the  tubercular  process.  Potassic  iodide  I  have 
found  useful  in  the  treatment  of  tubercular  lesions  complicated 
with  amyloid  degeneration  of  the  kidneys,  as  under  its  use  in 
such  cases  the  amount  of  albumen  in  the  urine  invariably  de- 
creased and  the  general  health  improved.  That  this  preparation 
of  iodine  exerted  a  favorable  influence  on  the  kidneys  was 


190  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

shown  by  increase  of  the  quantity  of  albumen  which  invariably 
occurred  after  suspension  of  its  use.  The  administration  of 
creasote,  as  advised  by  Sommerbrodt  in  the  treatment  of  pul- 
monary tuberculosis,  deserves  a  fair  trial  in  the  treatment  of 
tubercular  affections  of  bones  and  joints,  as  it  now  enjoys  great 
popularity  in  the  treatment  of  the  former  affection,  and  has 
yielded  more  favorable  results  than  any  other  remedy  heretofore 
suggested.  Creasote  should  be  given  in  one-  or  two-  drop  doses, 
made  into  a  mass  with  balsam  of  Peru  in  a  gelatin  capsule, 
three  or  four  times  a  day. 

The  different  preparations  of  mercury  which  at  one  time 
had  such  great  reputation  in  the  treatment  of  tumor  albus,  used 
internally  or  externally,  are  not  only  useless  but  positively  harm- 
ful in  this  and  other  forms  of  surgical  tuberculosis. 

Since  1878  Schiiller  ("Eine  neue  Behandlung  der  Tuber- 
kulose."  Berlin,  1891)  has  made  a  careful  study  of  the  thera- 
peutic value  of  guaiacol  in  the  treatment  of  different  forms  of 
tuberculosis.  He  first  studied  the  effect  of  this  drug  on  the 
growth  of  the  tubercle  bacillus  in  artificial  nutrient  media,  and 
found  that  it  had  a  decided  influence  in  arresting  further  growth 
of  the  culture.  He  then  made  a  series  of  experiments  on  ani- 
mals which  had  been  rendered  tubercular  by  inoculation,  and  a 
decidedly  curative  effect  was  observed.  The  tubercular  lesions 
were  carefully  examined  at  different  times  after  the  guaiacol 
treatment  was  commenced,  and  in  many  of  the  animals  further 
extension  of  the  tubercular  process  was  not  only  arrested,  but 
a  permanent  cure  was  effected,  while  all  of  the  control  animals 
died.  In  animals  under  the  influence  of  guaiacol  he  observed, 
in  the  affected  parts,  three  different  processes  by  which  the 
lesions  were  cured:  (1)  cicatricial  contraction  of  the  tubercles 
with  central  molecular  degeneration,  or  fatty  degeneration ;  (2) 
a  peculiar  softening  of  the  nodules  by  the  appearance  of  a  fine 
intercellular  net-work  of  juice-canals,  followed  by  vascularization 
of  tubercle  tissue  and  corresponding  changes  of  the  cellular  ele- 
ments, particularly  the  giant-cells;  (3)  ulcerative  destruction  of 


TREATMENT    OF    TUBERCULOSIS   OF   JOINTS.  191 

the  tubercle,  with  consecutive  cicatricial  contraction  .and  healing 
of  ulcer.  The  guaiacol  was  administered  by  inhalation,  by  subcu- 
taneous injection,  or  by  the  stomach.  This  author  became 
satisfied  long  ago  that  external  tuberculosis  is  only  a  peripheral 
manifestation  of  more  deeply  seated  occult  foci,  and  that  all 
kinds  of  local  treatment  are  inadequate  to  combat  the  disease 
successfully.  It  has  been  his  endeavor  to  find  some  drug  which, 
when  administered  in  sufficient  doses  and  for  a  requisite  length 
of  time,  should  prove  efficient  in  curing  inaccessible  existing 
lesions,  thus  preventing  re-infection  of  the  body.  Since  1885  he 
has  subjected  all  of  his  tubercular  patients  to  guaiacol  treatment, 
in  addition  to  appropriate  local  treatment.  Of  one  hundred 
cases,  seventy  were  cured,  sixteen  were  improved,  and  four  died ; 
during  the  treatment  only  three  died, — two  of  tubercular  menin- 
gitis and  one  of  an  intercurrent  diarrhoea.  At  first  he  adminis- 
tered the  drug  in  the  form  of  emulsion,  but  at  the  present  time 
he  gives  it  in  milk,  coffee,  beer,  or  any  other  pleasant  men- 
struum. According  to  the  age  of  the  patient,  he  gives  from  2 
to  5  drops  four  times  a  day.  He  places  great  stress  on  con- 
tinuing this  treatment  for  three  months  to  a  year  and  a  half. 
In  his  interesting  little  book  on  this  subject  he  gives  a  detailed 
account  of  over  one  hundred  cases  of  different  forms  of  tubercu- 
losis treated  by  this  drug,  and  the  results  obtained  in  many  of 
the  cases  were  certainly  such  that  could  not  be  attributed  solely 
to  the  local  treatment  which  was  conscientiously  employed  at 
the  same  time.  Local  relapses  and  general  dissemination  were 
more  effectually  prevented  than  by  any  known  local  method  of 
treatment  unassisted  by  such  general  treatment.  For  the  last 
four  months  every  tubercular  patient  in  my  clinic  and  hospital 
practice  has  been  placed  on  the  guaiacol  treatment,  and,  from 
the  experience  so  far  obtained,  I  believe,  with  the  most  happy 
results. 


CHAPTER  XX. 

LOCAL  TREATMENT. 

ALTHOUGH  the  existence  of  a  tubercular  bone  or  joint  affec- 
tion usually  is  only  an  indication  of  the  presence  of  an  older  tuber- 
cular focus  in  some  other  part  or  organ,  the  clinical  fact  remains 
that  the  primary  focus  frequently  remains  in  a  latent  condition, 
and  that  re-infection  is  more  likely  to  take  place  from  the  bone 
or  joint  lesion.  It  is  on  this  account  that  the  general  treatment, 
no  matter  how  well  it  may  be  planned  and  how  admirably  it 
may  be  executed,  can  never  supplant  the  necessary  local  treat- 
ment. The  local  treatment  consists  of  such  means  and  measures 
which  are  best  adapted  to  place  the  affected  parts  in  the  most 
favorable  conditions  to  undergo  a  spontaneous  cure,  and  if 
this,  the  ideal  result,  is  no  longer  attainable  on  account  of  the  ex- 
tent of  the  disease  or  the  character  of  the  structural  changes 
which  have  already  taken  place,  the  rendering  harmless  or  elim- 
ination of  the  infected  area  for  the  purpose  of  preventing  further 
local  and  general  infection,  and,  if  possible,  to  restore  function 
of  the  infected  part  or  limb.  The  local  treatment  must,  therefore, 
necessarily  vary  according  to  the  location,  extent  of  the  disease, 
and  the  character  of  the  inflammatory  product.  During  the 
early  stage  of  the  disease,  under  favorable  circumstances,  the 
simplest  local  treatment  may  prove  successful  in  arresting  fur- 
ther progress,  and  in  rendering  the  necessary  assistance  to  bring 
about  a  spontaneous  cure ;  while,  on  the  other  hand,  if  the  dis- 
ease is  extensive,  and  the  tissues  have  undergone  irreparable 
changes,  nothing  short  of  a  formidable  and  mutilating  operation 
will  answer  the  indications. 

Rest. — One  of  the  cardinal  points  in  the  treatment  of  in- 
flammatory processes,  irrespective  of  their  cause  or  causes,  is  to 
secure  for  the  inflamed  part  a  condition  approaching,  as  nearly 
as  it  is  possible,  absolute  physiological  rest.  While  it  is  gen- 
erally conceded  that  it  is  necessary  to  secure  rest  in  the  treat- 
(192) 


LOCAL   TREATMENT.  193 

ment  of  a  tubercular  affection  of  a  bone  or  joint,  there  can  be 
no  doubt  that  this  part  of  the  treatment  has  been  overdone,  and 
has  resulted  in  a  great  deal  of  harm  to  limb  and  patient.  It  is 
one  of  the  most  difficult  things  in  surgery  to  decide  how  long  rest 
should  be  continued  in  the  treatment  of  an  inflamed  joint.  No 
absolute  rules  can  be  laid  down  to  decide  this  matter.  Enforced 
rest,  continued  beyond  the  time  it  is  required,  has  resulted  in 
serious  damage  to  joints  in  which  an  earlier  suspension  of  this 
part  of  treatment  would  have  yielded  much  better  functional 
results.  The  injurious  effects  of  prolonged  rest  on  healthy 
joints  have  been  made  the  subject  of  careful  clinical  and  ex- 
perimental studies.  Volkmann  ("  Ueber  den  Hydarthros  steif 
gehaltener  Gelenke."  BerL  Idin.  Wochenschrift,  No.  30-31, 
1870)  reported,  in  1870,  twenty  cases  of  effusion  into  otherwise 
healthy  joints,  that  had  been  immobilized  for  a  number  of 
weeks  in  the  treatment  of  fractures  and  adjacent  diseased 
joints.  The  joint  affection  usually  appeared  soon  after  the  pa- 
tient made  the  first  attempt  to  use  the  limb.  The  effusion,  as 
a  rule,  made  its  appearance  in  a  short  time,  and  varied  much 
as  to  amount.  Volkmann  attributes  the  hydrops  to  the  rigidity 
of  the  synovial  membrane  and  periarticular  connective  tissue, 
caused  by  the  prolonged  rest  and  immobilization.  The  move- 
ments in  the  joint  produced  harmful  traction  upon  the  short- 
ened and  rigid  -  structures,  producing  distortion  and  its  conse- 
quence,—  distortion-arthro-meningitis.  The  effusion  usually 
disappears  spontaneously,  as  soon  as  the  capsule  of  the  joint 
is  restored  to  its  normal  conditions. 

In  view  of  this  experience,  the  author  asserted  that  it  was 
difficult  for  him  to  decide  in  how  far  rest  and  systematic  use  of 
a  joint  may  be  resorted  to  with  greatest  advantage  in  the  treat- 
ment of  chronic  synovitis. 

The  late  Professor  Reyher,  of  St.  Petersburg  ("  Ueber  die 
Veranderangen  der  Gelenke  bei  dauernder  Ruhe."  Deutsche 
Zeitschrift  f.  Chiriirgie^  B.  cxi,  p.  189),  made  quite  numerous 
experiments  on  young  dogs  to  ascertain  the  effects  of  prolonged 


194  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

uninterrupted  rest  on  the  structure  of  joints  that  had  been  per- 
fectly immobilized  in  a  plaster-of-Paris  dressing.  He  found,  in 
joints  thus  treated,  that  after  the  sixty-second  day  the  articular 
cartilage,  at  points  where  the  surfaces  did  not  come  in  contact, 
had  gradually  been  transformed  into  connective  tissue.  He 
maintained  that  the  cartilage  cells  were  transformed  into  con- 
nective-tissue cells.  This  transformation  was  first  observed  in 
the  superficial  layers  of  the  cells ;  the  process  extended  gradually 
deeper  until  the  entire  thickness  of  the  cartilage  became  in- 
volved in  this  change.  The  capsule  of  the  joint  became  thick- 
ened not  from  hyperplastic  changes,  but  shrinkage  of  the 
tissues,  which  at  the  same  time  became  more  compact. 

Menzel  ("  Ueber  die  Erkrankung  der  Gelenke  bei  dauern- 
der  Ruhe  derselben."  Arcliiv  fur  Idinische  Chirurgie,  B.  xii, 
p.  990)  made  a  similar  series  of  experiments  on  rabbits.  The 
time  the  joints  were  immobilized  varied  from  a  few  weeks  to 
sixty-eight  days.  He  found  that,  in  consequence  of  the  pro- 
longed rest,  fibrous  degeneration,  erosion,  and  colloid  soften- 
ing of  the  articular  cartilage  occurred,  but  he  found  these 
changes  most  marked  at  points  where  the  pressure  between  the 
articular  surfaces  was  greatest,  while  Reyher  found  them  in 
parts  of  the  articular  surfaces  not  subjected  to  pressure.  He 
attributes  these  changes  to  the  effect  of  prolonged  pressure,  as 
he  found  atrophic  and  degenerative  changes,  most  advanced 
where  pressure  was  greatest  and  continued  for  the  greatest 
length  of  time.  He  also  found  the  synovial  membrane  changed, 
swelling,  injection  of  vessels,  desquamation  of  endothelial  cells, 
and  sometimes  a  pterygium-like  proliferation. 

These  experiments  furnish  substantial  evidence  of  the  fact 
that  rest,  like  all  other  valuable  therapeutic  measures,  has  its 
limits  of  application,  and  when  these  are  surpassed  it  results  in 
more  harm  than  good.  Rest  is  indicated  as  long  as  movements 
in  the  joint  cause  pain  and  the  pain  thus  produced  is  due  to 
inflammation  of  the  structures  of  the  joint ;  it  is  also  absolutely 
necessary  in  the  treatment  of  suppurating  joints.  Both  active 


LOCAL   TREATMENT.  195 

and  passive  motion  in  a  joint  the  seat  of  extensive  disease 
must  result  in  aggravation  of  the  local  conditions,  and,  at  the 
same  time,  become  a  direct  cause  of  local  and  general  dissem- 
ination by  forcing  mechanically  tubercle  bacilli  or  even  small 
fragments  of  infected  tissue  into  the  surrounding  connective- 
tissue  spaces  or  the  veins.  A  joint  often  remains  tender  and 
painful  for  an  indefinite  period  of  time,  even  after  all  other 
evidences  of  inflammation  have  subsided,  and  it  is  in  this  class 
of  cases  that  the  best  judgment  is  necessary  to  decide  when  it 
is  best  to  substitute  active  and  passive  motion  for  rest.  In 
tubercular  hydrops  of  joints  and  in  fungous  synovitis  moderate 
use  of  the  joint  does  not  interfere  with  the  proper  treatment  for 
these  affections,  and  immobilization  in  such  cases  is  superfluous 
and  often  positively  injurious.  It  is,  however,  entirely  different 
in  osteo-arthritis  and  advanced  cases  of  primary  synovial  tuber- 
culosis, as  in  these  instances  pain  is  a  conspicuous  symptom  and 
is  always  aggravated  by  any  attempt  to  move  or  use  the  joint; 
at  the  same  time,  the  tendency  in  these  cases  to  contractures  is 
always  apparent,  and  serious  deformities  can  only  be  prevented  or 
corrected  by  proper  mechanical  support.  Extension  of  a  primary 
osseous  focus  to  an  adjacent  joint  is  hastened  by  use  of  the 
limb,  and  for  this  reason  alone  it  would  become  necessary  to 
secure  rest  for  the  joint  in  the  treatment  of  primary  tuberculosis 
of  bone.  Rest  for  an  inflamed  joint  is  secured  in  different 
ways,  according  to  location  of  the  disease  and  the  intensity  of 
the  inflammatory  process.  The  most  perfect  rest  is  attained  by 
the  recumbent  position  in  bed,  combined  with  immobilization 
of  joint  by  a  proper  fixation  dressing. 

Rest  in  Bed. — The  recumbent  position  secures  for  the  ex- 
tremities and  the  spinal  column  the  most  favorable  conditions 
for  rest,  and  if  the  inflamed  part  is  at  the  same  time  placed  in 
proper  position  it  will  be  a  valuable  aid  to  the  enfeebled  circu- 
lation in  the  affected  bone  or  joint.  Enforced  rest  in  bed 
becomes  necessary  in  the  treatment  of  most  cases  of  hip-joint 
disease,  with  or  without  extension,  and  is  indispensable  in  the 


196  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

early  treatment  of  tubercular  spondylitis  not  amenable  to  treat- 
ment by  extension  and  fixation  in  a  plaster-of-Paris  cast.  In 
the  latter  class  of  cases  the  patient  should  be  placed  upon  his 
back,  with  the  affected  portion  of  the  spine  resting  on  a  Ranch- 
fuss  swing,  securing  thus,  at  the  same  time,  rest  and  extension. 
As  prolonged  confinement  in  bed  lias  an  unfavorable  effect  on 
the  general  health  of  the  patient,  this  part  of  treatment  should 
not  be  prolonged  beyond  the  time  required  to  meet  the  local 
indications.  A  portable  bed  should  be  used  in  all  cases  requir- 
ing rest  in  bed  for  a  long  time,  so  that  the  patient  can  be  taken 
from  one  room  to  another  and,  whenever  practicable,  into  the 
open  air  without  interrupting  rest  and  extension,  and  at  the 
same  time  reduce  the  danger  incident  to  prolonged  confinement 
by  supplying  an  abundance  of  sunlight  and  pure  air. 

Immobilization  of  Joints. — Immobilization  of  a  joint  is  not 
only  indicated  when  a  joint  itself  is  the  primary  seat  of  the  dis- 
ease, as  this  method  of  treatment  is  also  of  great  value  in  the 
treatment  of  tubercular  disease  of  bone  if  the  primary  focus  is 
located  in  the  body  of  a  vertebra  or  the  epiphysial  extremity  of 
a  long  bone.  Immobilization  of  the  vertebral  column  in  tuber- 
cular spondylitis  can  be  effected  most  advantageously  by  extend- 
ing the  spine  to  the  point  of  comfort  and  fixing  the  trunk  in  this 
position  in  a  plaster-of-Paris  dressing  according  to  the  method 
so  fully  perfected  by  Sayre.  Rest  and  fixation  of  the  shoulder- 
joint  can  be  secured  by  placing  the  forearm  in  a  sling  and  fast- 
ening the  arm  to  the  side  of  the  chest  with  a  broad  strip  of 
adhesive  plaster  or  bandage  encircling  the  chest.  Cheap,  com- 
fortable, and  useful  fixation  splints  can  be  made  of  wire  gauze, 
which  is  sold  by  the  yard  and  can  be  cut  into  strips  of  the  de- 
sired length  and  width  with  a  pair  of  stout  shears.  These 
splints  can  be  bent  at  any  desirable  angle,  and  can  be  molded 
accurately  to  the  limb.  When  carefully  padded  with  absorbent 
cotton  they  fit  the  limb  occurately  and  give  uniform,  equable 
support.  As  a  rule,  they  should  embrace  one-half  or  two-thirds 
of  the  circumference  of  the  limb.  The  most  efficient  fixation 


LOCAL   TREATMENT.  197 

dressing  is  the  permanent  circular  splint  made  of  plaster-of-Paris, 
starch,  dextrin,  or  water-glass.  A  splint  of  this  kind  must  be 
applied  with  the  greatest  care,  in  order  to  prevent  gangrene  from 
circular  constriction  and  decubitus  from  pressure.  A  layer  of 
absorbent  cotton,  at  least  an  inch  thick,  should  surround  the 
limb,"  and  special  padding  over  subcutaneous  bony  prominences 
must  be  provided  for,  and  the  splint  applied  from  the  periphery 
of  the  limb ;  starting,  for  instance,  from  the  toes  in  using  this 
dressing  for  the  lower  extremity,  and  from  the  metacarpo- 
phalangeal  joints  for  the  upper.  Patients  wearing  a  circular, 
plastic,  permanent  splint  should  always  remain  under  the  obser- 
vation of  the  surgeon,  and  should  be  frequently  seen  in  order  to 
prevent  disastrous  consequences.  Fixation  splints  for  elbow-  and 
wrist-  joints  should  never  extend  farther  than  the  base  of  the 
fingers,  as  when  these  are  confined  in  the  dressing  in  the  ex- 
tended position,  even  for  a  short  time,  more  or  less  stiffness  will 
surely  result  from  the  faulty  position.  In  tubercular  disease  of 
the  elbow-joint,  requiring  in  its  treatment  long-continued  rest 
and  fixation,  the  forearm  should  be  flexed  upon  the  arm  at  right 
angles,  and  in  a  position  half-way  between  pronation  and  supi- 
nation,  with  the  arm  and  forearm  supported  upon  a  posterior 
wire-gauze  splint.  Immobilization  of  the  wrist-joint  can  be 
effectually  attained  by  confining  the  forearm  and  dorsum  of 
hand  upon  a  posterior  splint,  with  the  hand  in  a  straight  or 
slightly  extended  position.  The  sling  is  a  necessary  supplemen- 
tary appliance  in  connection  with  all  fixation  dressings  of  the 
upper  extremity.  In  the  treatment  of  bone  and  joint  tubercu- 
losis of  the  lower  extremities,  a  fixation  dressing  is  only  to  be 
applied  when  the  limb  is  in  a  useful  position  or  after  it  has  been 
brought  into  such  by  appropriate  treatment.  Flexion  of  the 
thigh  upon  the  pelvis  in  hip-joint  disease,  and  of  the  leg  in 
tubercular  disease  of  the  knee-joint,  must  be  treated  by  rest  in 
bed  and  extension  by  weight  and  pulley  until  the  limb  is  brought 
into  a  useful  position  before  either  of  these  joints  are  immobilized. 
The  only  dressing  which  can  fix  the  hip-joint  completely  is  a 


198  TUBERCULOSIS  Of1   THE   BONES   AND   JOINTS. 

plaster-of-Paris  dressing  embracing  the  affected  limb,  the  pelvis, 
and  the  opposite  limb  as  far  as  the  knee-joint.  Fixation  of  the 
knee-joint,  when  the  limb  is  in  proper  position,  can  be  effected 
by  the  use  of  a  hollow  posterior  splint  extending  from  the 
tuberosity  of  the  ischiurn  the  whole  length  of  the  limb,  with  a 
foot-board  attached  at  right  angles,  against  which  the  foot  is 
fastened  with  a  few  strips  of  adhesive  plaster  or  a  roller  bandage, 
or  the  limb  is  encased  in  a  permanent,  circular,  fixation  dressing. 
In  the  treatment  of  diseases  of  the  ankle-joint  the  foot  should 
always  be  placed  at  a  right  angle  to  the  leg  and  then  immobi- 
lized in  this  position.  If  there  is  a  probability  that  the  disease 
will  terminate  in  complete  or  partial  ankylosis,  the  joint  should 
be  immobilized  in  a  position  in  which  the  limb  will  be  of  great- 
est use  subsequently,  which,  in  the  hip-  and  knee-  joints,  is  a 
slight  degree  of  flexion:  ankle-joint,  foot  at  right  angles  to  the 
leg;  elbow-joint,  forearm  flexed  so  that  the  patient  can  reach 
the  mouth  with  the  hand,  wrist  straight.  Whatever  kind  of 
fixation  splint  is  used,  it  is  necessary  to  remove  it  every  few  days 
or  weeks  for  a  thorough  inspection  of  the  joint  and  limb,  and  to 
ascertain  if  it  is  producing  undue  pressure  at  any  point.  The 
patient  must  be  instructed  in  reference  to  the  symptoms  indicat- 
ing such  an  occurrence  and  requested  to  report  at  once  should 
these  arise. 

Extension.  —  As  a  therapeutic  resource  in  surgery  per- 
manent extension  was  known  to  Guy  de  Chauliac ;  Heister 
mentions  it,  and  Bell  alludes  to  it  in  commenting  upon  the 
treatment  of  fractures  of  the  femur.  In  America  it  was  first 
used  by  Tyson,  in  1819,  and  described  ten  years  later.  This 
method  of  treatment  appears  to  have  been  entirely  forgotten 
until  it  was  again  revived  by  Luke  Howe  (1824),  Dugas 
(1839),  and  more  recently  by  Gordon  Buck.  In  1830  Swift, 
of  Easton,  Pa.,  the  preceptor  of  the  late  Prof.  S.  L).  Gross, 
used  strips  of  adhesive  plaster  for  making  the  extension,  and 
in  1844  Wallace  introduced  this  technique  as  a  routine  treat- 
ment in  the  Pennsylvania  Hospital,  and  the  method  was  fully 


LOCAL   TREATMENT.  199 

described  by  Sargent  the  same  year.  Benj.  Brodie  was  the 
first  one  to  apply  this  method  in  the  treatment  of  inflammation 
of  joints ;  but  the  credit  of  establishing  it  as  a  legitimate  pro- 
cedure in  practice  in  the  treatment  of  joint  affections  belongs  to 
G.  Ross,  who  wrote  elaborately  on  the  subject  in  1854.  A 
great  deal  has  been  said  and  written  on  the  value  and  modus 
operaiidi  of  permanent  extension  in  the  treatment  of  diseased 
joints.  The  more  enthusiastic  exponents  of  this  method  of 
treatment  maintain  that  the  beneficial  results  are  due  to  a  sepa- 
ration of  the  inflamed  articular  surfaces,  while  others  claim  that 
such  an  effect  under  ordinary  circumstances  is  not  realized,  and 
that  the  beneficial  results  following  its  use  are  due  entirely  to 
the  abatement  of  muscular  spasms  and  the  rest  which  it  secures 
for  the  joint. 

Volkmann  ("  Ueber  die  Behandlung  der  Gelenkentziin- 
dungen  mit  Gewichten."  Berl.  kiln.  Wochenschrift,  Nos. 
5-6,  1868)  taught  that  permanent  extension  in  the  treatment 
of  inflamed  joints  proves  useful  by  diminishing  the  mutual 
pressure  between  the  inflamed  surfaces, — a  doctrine  strongly 
supported  by  Sayre  and  most  orthopaedic  surgeons. 

Schultze  ("  Untersuchungen  iiber  die  Distractionsfahigkeit 
der  Grossen  Extremetatengelenke."  Deutsche  Zeitsclirift  f. 
Chirurgie,  B.  viii)  believes  that  extension  not  only  diminishes 
the  mutual  pressure  between  the  articular  ends  of  the  bones, 
but  that  it  can  be  carried  to  such  an  extent,  in  the  treatment  of 
inflamed  joints,  as  to  separate  the  surfaces  completely.  In  his 
experiments  on  the  cadaver  he  succeeded  in  separating  the- 
articular  surfaces  of  the  knee-joint  under  a  traction  of  twenty- 
five  pounds  continued  for  .forty-eight  hours,  one  millimetre  on 
the  inner  and  one  millimetre  and  a  half  on  the  outer  side.  If 
he  immobilized  the  femur  completely  the  same  traction  force  in 
twenty-four  hours  doubled  the  diastasis. 

In  the  shoulder-joint  the  separation  effected  under  eight 
pounds  of  traction  force  amounted  to  three  and  a  half  milli- 
metres. The  same  traction  force  produced  a  similar  effect  in 


200  TUBERCULOSIS   OF   THE   BONES   AND    JOINTS. 

the  wrist-joint.  W.  Busch  ("  Beitrage  ziir  mechanischen 
Behandlung  der  Gelenkentziindung."  Archie  f.  Idin.  Chi- 
rurgie,  B.  xiv,  p.  77)  is  of  the  opinion  that  the  favorable 
results  of  the  treatment  of  inflamed  joints  by  extension  is  not 
owing  so  much  to  the  separation  by  the  traction  of  the  diseased 
articular  surfaces  as  to  the  shifting  of  the  pressure-point  within 
the  joint,  brought  about  by  the  gradual  extension  of  the  limb. 
He  asserts  that  the  extension  of  a  contracted  knee-  or  hip- 
joint  does  not  diminish  but  increases  the  intra-articular  press- 
ure. '  He  claims  that  the  increased  intra-articular  pressure 
caused  by  the  extension  promotes  absorption,  and  to  this  and 
the  changed  position  of  the  limb  he  attributes  the  favorable 
results  obtained  by  extension. 

Lannelongue  ("  Notes  cliniques  et  experiment,  sur  Peffet 
de  Pextension  continue  sur  les  articulations  malades  et  sur  la 
coxalgie  tuberculeuse  la  particulier."  Revue  de  Chir.,  vi,  2,  p. 
163)  had  an  excellent  opportunity  to  study  the  effect  of  exten- 
sion on  diseased  joints  in  a  child  4  years  old,  that  had  been 
suffering  for  five  months  from  coxitis  and  died  of  croup.  Treat- 
ment by  extension  had  been  carried  out  for  forty-five  days  prior 
to  death.  After  the  death  of  the  child  extension  was  applied 
and  the  body  frozen.  Section  through  the  joint  showed  that 
the  articular  surfaces  were  separated;  and  Lannelongue  is  of  the 
opinion  that  this  effect  can  be  brought  about  by  extension  in 
diseased  joints,  and  that  to  it  should  be  attributed  the  beneficial 
results  of  this  method  of  treatment.  One  of  the  first  effects  of 
extension  in  the  treatment  of  coxitis  is  diminution  of  pain, 
especially  the  nocturnal  exacerbations  caused  by  the  reflex  mus- 
cular spasms ;  and  as  this  result  is  obtained  in  primary  osseous 
tuberculosis  as  well  as  when  the  joint  is  implicated,  it- is  evidently 
the  outcome  of  rest  and  cessation  of  muscular  spasms,  and  not 
separation  of  the  articular  surfaces.  In  advanced  cases  of  joint 
disease  the  ill  effects  of  pressure-atrophy  in  the  diseased  articu- 
lar extremities  are  diminished  by  the  extension  treatment.  The 
same  treatment  also  exerts  an  important  orthopaedic  influence, 


GF 


JrU/'-J'-ff 

LOCAL   TREAfMENT. 

as  it  brings  the  limb  into  the  most  desirable  position  and  dimin- 
ishes the  liability  to  permanent  contractures  from  pressure- 
atrophy  and  cicatricial  contraction  of  the  synovial  membrane 
and  capsule  of  the  joint.  Permanent  extension  is  indicated  in 
the  treatment  of  inflammation  of  the  hip-  and  knee-  joints 
which  has  already  given  rise  to  muscular  contraction  and  de- 
formity. In  the  absence  of  these  secondary  results  it  is  better 
to  resort  to  some  of  the  different  immobilization  dressings  which 
will  not  confine  the  patient  to  his  bed.  Extension  is  a  safe  and 
exceedingly  valuable  resource  in  the  prevention  and  correction 
of  recent  contractures  about  the  knee-  and  hip-  joints.  The 
simplest  method  to  make  extension  is  by  the  use  of  weight  and 
pulley.  Ordinary  adhesive  plaster  is  very  prone  to  cause  irrita- 
tion of  the  skin  in  young  children  and  in  persons  with  a  thin, 
delicate  skin,  and  on  this  account  a  non-irritating  adhesive  sub- 
stance should  be  used.  Either  the  ordinary  lead  plaster  or  the 
English  moleskin  adhesive  plaster  answers  an  excellent  purpose. 
Tlie  great  rule  which  should  guide  the  surgeon  in  making  ex- 
tension of  a  limb  that  has  become  contracted  by  tubercular  dis- 
ease of  a  joint  or  one  or  more  of  the  epiphysial  extremities  is 
to  make  first  the  traction  in  the  direction  of  the  faulty  axis,  and 
only  gradually  change  the  angle  until  the  desired  position  is 
reached.  If  the  thigh  is  much  flexed  in  hip-joint  disease  or  the 
leg  in  inflammation  of  the  knee-joint  it  will  often  be  found 
advantageous  to  place  the  limb  upon  a  double  inclined  plane, 
and  in  the  former  case  apply  extension  to  the  thigh  alone  in  the 
direction  the  limb  has  assumed  and  gradually  diminish  the  angle 
of  the  inclined  plane  until  this  can  be  dispensed  with  and  ex- 
tension applied  in  the  usual  way.  In  the  latter  case  the  same 
precautions  are  carried  out.  Extension  in  the  normal  axis  of 
the  limb  in  such  cases  can  often  not  be  borne  on  account  of  the 
pain  which  it  causes;  at  the  same  time,  by  increasing  the  press- 
ure between  the  articular  surfaces  at  a  point  where  the  disease 
is  most  advanced,  it  would  rather  favor  than  prevent  subluxation. 
The  amount  of  traction  to  be  employed  must  necessarily  vary 


oii-iv/vie  - 


,    i- 

TJJ 


.14 

TUBERCULOSIS   OF   THE    BONES    AND   JOINTS. 


from  two  to  twenty-five  pounds,  according  to  the  age  of  the 
patient  and  the  nature  of  the  indications  to  be  fulfilled.  The 
safest  rule  to  follow  is  to  commence  with  a  small  weight  and 
gradually  increase  it  until  the  proper  amount  is  reached.  Ex- 
tension is  only  the  preparatory  treatment  for  the  use  of  a  fixation 
dressing,  and  should  be  suspended  as  soon  as  the  limb  has  been 
brought  into  a  useful  position,  as  when  it  is  continued  beyond 
this  time  it  ceases  to  be  of  any  benefit  and  may  seriously  impair 
the  subsequent  functional  utility  of  the  joint.  Contra-exten- 


FIG.  32.— PERMANENT  EXTENSION  BY  WEIGHT  AND  PULLEY  IN  THREE 
DIRECTIONS  IN  DISEASE  OF  THE  KNEE-JOINT  WHICH  WAS  CAUSED  BY 
FLEXION  AND  SUBLUXATION  OF  THE  TIBIA  BACKWARD.  (Krause.) 

sion  is  made  by  the  weight  of  the  body  by  raising  the  foot  of 
the  bed.  Direct  con tra-exten sion  is  unnecessary  and  a  source 
of  great  inconvenience  and  often  of  actual  suffering  to  the  patient. 
In  some  cases  it  is  necessary  to  make  extension  in  more  than 
one  direction  for  the  purpose  of  correcting  deformities  caused 
by  the  intra-articular  disease.  Fig.  32  furnishes  a  good  illustra- 
tion of  the  indications  and  application  of  multiple  extension  in 
the  treatment  of  inflamed  and  deformed  joints. 


LOCAL   TREATMENT.  203 

Hutchinson,  of  Brooklyn  ("  On  the  Mechanical  Treatment 
of  Chronic  Inflammation  of  the  Hip-,  Knee-,  and  Ankle-  Joints 
by  a  Simple  and  Efficient  Method,  the  Physiological  Method, 
with  Cases."  Medical  Record,  No.  10, 1879),  has  devised  a  very 
simple  and  yet  effective  method  of  making  extension  in  the 
treatment  of  the  larger  joints  of  the  lower  extremity.  The 
patient  is  made  to  walk  on  crutches,  the  healthy  limb  being 
supplied  with  a  shoe  provided  with  a  raised  sole.  The  affected 
limb  being  suspended  makes  the  necessary  extension  by  its  own 
weight ;  so  that  this  simple  device  secures  both  rest  and  extension, 
while  the  patient  has  the  benefit  of  out-door  air  and  exercise. 
Hutchinson  claims  that  in  coxitis  the  numerous  muscles  sur- 
rounding the  hip-joint  immobilize  the  joint  sufficiently,  while 
in  the  treatment  of  inflammation  of  the  knee-  and  ankle-  joints 
he  advises  immobilization  by  some  kind  of  a  fixation  dressing 
in  connection  with  the  auto-suspension  treatment.  This  method 
of  making  extension  is  of  special  utility  in  the  treatment  of 
affections  of  the  large  joints  of  the  lower  extremity  during  the 
early  stage.  It  is  also  valuable  in  the  after-treatment  of  cases 
in  which  by  previous  treatment  the  inflammation  has  been 
lessened  and  deformity  corrected,  as  well  as  after  excision  of 
joints  as  soon  as  the  patient  is  able  to  leave  his  bed. 

Portable  Extension  Apparatus. — Recognizing  the  delete- 
rious effects  of  prolonged  rest  in  bed,  necessitated  by  making 
permanent  extension,  on  the  general  health  of  patients  suffering 
from  tubercular  affections  of  the  large  joints  of  the  lower  ex- 
tremity, orthopaedic  surgeons  have  devised  a  number  of  inge- 
nious instruments  with  the  expectation  that  they  would  answer 
the  same  purpose  as  permanent  extension  minus  the  disadvan- 
tages incident  to  in-.door  confinement.  The  instruments  best 
known,  and  which  have  given  most  satisfaction,  are  those  in- 
vented by  Taylor,  Davis,  Say  re,  Volkmann,  Bauer,  Hutchinson, 
and  Thomas.  The  more  costly  and  complicated  instruments 
are  now  seldom  used.  The  one  which  is  used  most  now  in  the 
treatment  of  hip-joint  disease  is  the  Thomas  splint.  It  is  the 


204  TUBERCULOSIS   OP   THE   BONES   AND   JOINTS. 

simplest,  cheapest,  and  yet  the  most  efficient  apparatus  in  limit- 
ing motion  in  the  hip-joint  in  patients  that  are  able  to  walk  on 
crutches.  The  claim  made  for  these  instruments  that  they,  if 
properly  applied,  would  prevent  pressure  between  the  joint  sur- 
faces is  unfounded.  No  patient  would  bear  for  any  length  of 
time  the  amount  of  traction  and  counter-traction  to  accomplish 
this  object.  None  of  these  splints  are  of  any  use  unless  the 
limb  is  nearly  in  a  straight  position,  and  they  are,  therefore, 
at  best  only  supplementary  aids  to  permanent  extension,  in  the 
majority  of  cases.  Hutchinson's  method  of  suspending  the 
affected  limb  makes  more  efficient  extension  than  any  of  the 
so-called  extension  splints,  while  immobilization  is  more  per- 
fectly attained  by  some  one  of  the  fixation  dressings  already  re- 
.  ferred  to.  A  circular  or  removable  fixation  splint,  combined  with 
extension,  as  advised  by  Hutch inson,  is  by  far  a  more  efficient 
treatment  than  the  use  of  extension  solints,  and,  at  the  same 
time,  more  comfortable  to  the  patient. 


CHAPTER   XXI. 

LOCAL  TREATMENT  (continued). 

Brisement  Force. — The  rapid  correction  of  deformities  pro- 
duced by  paralysis,  inflammation  of  bones  and  joints,  is  called 
brisement  force  or  redressement.  Forcible  extension  of  a  con- 
tracted limb  is  now  less  frequently  resorted  to,  because  experience 
has  shown  that  efforts  of  this  kind  have  often  been  followed  by 
an  acute  destructive  inflammation  of  the  joint,  and  in  operations 
done  for  tubercular  affections,  even  by  miliary  tuberculosis. 
( Verchere  Progres  Medical,  1886,  No.  24.)  This  procedure 
should  be  limited  to  recent  cases  if  for  any  reasons  permanent 
extension  is  not  applicable  or  has  proved  inefficient,  and,  later, 
again  after  the  inflammatory  process  has  subsided  and  has  left 
the  limb  in  a  contracted  condition.  It  is  positively  contra- 
indicated  if  fistulous  openings  lead  into  a  suppurating  joint, 
and  if  thin  scars  adherent  to  the  articular  extremities  are  in  the 
way  of  complete  extension,  as  such  scars  are  liable  to  be  torn 
by  the  sudden  efforts  to  straighten  the  limb, — an  accident  which 
might  lead  to  serious  results.  It  is  also  not  applicable  in  cases 
where  the  disease  has  resulted  in  partial  dislocation  of  the  ar- 
ticular extremities,  as  under  such  circumstances  the  forcible 
straightening  of  the  limb  might  increase  or  complete  the  disloca- 
tion. This  is  especially  true  in  the  case  of  partial  dislocation  of 
the  head  of  the  tibia  backward  with  outward  rotation  of  the  leg. 
In  well-selected  cases  this  method  of  treatment  expedites  the  cure 
and  places  the  limb  at  once  in  a  useful  position.  In  the  second 
class  of  cases  intra-articular  adhesions  and  muscular  contrac- 
tures  are  to  be  overcome  by  manual  force.  It  is  necessary  to 
operate  under  full  anaesthesia  in  order  to  remove  all  resistance 
caused  by  muscular  contractions.  The  amount  of  force  to  be 
employed  must,  of  course,  depend  on  the  age  of  the  patient, 
the  size  of  the  joint,  the  degree  of  deformity,  and  the  nature  of 
the  mechanical  difficulties  which  have  to  be  overcome.  A  great 

(205) 


206  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

deal  of  good  judgment  is  necessary  in  grading  the  force  in  each 
case.  In  children,  a  force  necessary  to  correct  a  faulty  position, 
due  to  partial  or  fibrous  ankylosis,  may  produce  a  fracture 
through  the  epiphysial  line.  If  the  muscles  on  the  flexor  side 
have  become  so  much  shortened  as  to  offer  the  principal  resist- 
ance to -extension,  tcnotomy  or  myotomy  should  be  done  before 
a  forcible  attempt  is  made  to  straighten  the  limb.  If  the  intra- 
articular  adhesions  are  so  firm  that  it  would  require  an  undue 
amount  of  force  to  correct  the  faulty  position  at  one  sitting,  it  is 
safer  to  be  content  with  a  partial  result  and  repeat  the  effort 
after  two  or  three  weeks,  making  use  during  the  interval  of  per- 
manent extension.  If  a  safe  amount  of  force  yield  little  or  no 
gain,  brisement  force  should  give  way  to  an  osteotomy  or  ex- 
cision, as  both  of  these  operations  are  less  dangerous  than  the 
use  of  undue  violence,  and  will  enable  the  surgeon  to  place  the 
limb  in  a  position  adapted  to  a  favorable  functional  result.  If 
the  redressement  prove  successful,  the  limb  is  placed  in  a  de- 
sirable position  and  immobilized  until  the  reaction  following  the 
operation  has  subsided.  If  the  intra-articular  conditions  are 
such  that  it  appears  possible  and  desirable  to  obtain  a  movable 
joint,  active  and  passive  motion  are  now  instituted ;  and  if  a 
tendency  to  recurrence  of  deformity  is  observed,  permanent  ex- 
tension or  a  fixation  dressing  is  to  be  relied  upon  in  maintain- 
ing what  has  been  gained  by  the  redressement.  If  the  articular 
surfaces  have  been  so  much  changed  by  the  inflammatory  proc- 
ess as  to  preclude  the  possibility  of  obtaining  a  movable  useful 
joint,  the  limb  is  to  be  kept  immobilized  in  proper  position  until 
the  ankylosis  has  become  sufficiently  firm  to  prevent  recurrence 
of  the  deformity. 

External  Local  Treatment. — A  correct  knowledge  of  the 
true  etiology  of  bone  and  joint  tuberculosis  has  done  away  with 
the  time-honored  external  local  treatment,  consisting  of  cupping, 
leeching,  blistering,  poultices,  lotions,  plasters,  salves,  etc.  Mod- 
ern surgery  has  shown  that  the  use  of  external  remedies  of  every 
description  exert  no  direct  healing  powers  on  the  intra-osseous 


LOCAL   TREATMENT.  '  207 

or  intra-articular  lesions,  and  that  all  the  best  of  them  can 
accomplish  is  to  improve  the  circulation  in  the  affected  parts, 
and  thus  indirectly  influence  favorably  the  healing  process. 

Compression. — The  value  of  equable,  long-continued  com- 
pression of  parts  the  seat  of  chronic  inflammation  is  well  known. 
The  artificial  external  support  supplied  in  this  manner  assists 
the  weakened,  inflamed  capillary  vessels  and  promotes  the  ab- 
sorption of  the  inflammatory  product.  This  therapeutic  measure 
is  of  no  value  in  the  treatment  of  bone  tuberculosis  as  long  as 
the  inflammatory  process  remains  intra-osseous..  Its  beneficial 
effect  is  most  marked  in  fungous  synovitis  and  after  tapping  or 
aspiration  of  a  joint  for  tubercular  hydrops.  Circular  compres- 
sion made  with  a  flannel  or  elastic  bandage  or  strips  of  adhesive 
plaster  requires  great  care,  as,  in  case  the  circular  constriction  is 
too  firmly  applied,  it  might  interfere  with  or  arrest  completely 
the  circulation  in  the  peripheral  portion  of  the  limb.  In  mak- 
ing circular  compression  of  a  joint  the  limb  must  be  carefully 
bandaged  from  the  periphery  as  far  as  the  joint,  which  is  then 
supported  by  strips  of  adhesive  plaster,  which  are  made  to  cross 
each  other  in  front  at  an  obtuse  angle ;  or  the  joint  and  the  limb, 
for  some  distance  below  and  above  it,  is  compressed  with  an 
elastic-webbing  bandage,  which  is  applied  with  sufficient  firm- 
ness to  give  uniform  support  without  interfering  with  the  circu- 
lation in  the  deep  vessels.  In  some  cases  it  is  advisable  to  com- 
bine compression  with  fixation  of  the  joint.  These  objects  are 
attained  to  a  certain  degree  by  a  circular  fixation  dressing,  by 
interposing  between  the  joint  and  the  splint  a  thick  layer  of 
absorbent  cotton,  light  pressure  being  made  by  the  elastic-cot- 
ton compress.  In  other  cases,  especially  in  the  treatment  of 
chronic  inflammation  of  the  knee-joint,  the  limb  is  bandaged 
from  the  toes  to  the  knee-joint  and  fixation  secured  upon  a 
posterior  hollow  splint,  when  compression  is  made  with  strips 
of  adhesive  plaster,  which  encircle  the  anterior  portion  of  the 
joint  and  the  splint.  This  method  of  making  compression  is 
particularly  useful  after  tapping  the  knee  for  tubercular  hydrops. 


208  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

As  the  compression  should  be  continuous,  the  dressing  must  be 
changed  as  often  as  it  becomes  loose. 

Cold. — This  therapeutic  agent  has  no  direct  influence  in 
removing  the  cause  of  tubercular  inflammation,  but  has  proved 
serviceable  in  favorably  modifying  the  inflammatory  process 
when  used  at  the  right  time  and  in  a  proper  manner.  If  used 
indiscriminately  and  empirically  it  will  result  in  harm.  Cold  is 
a  potent  agent  for  good  or  harm,  according  to  the  stage  of  in- 
flammation during  which  it  is  applied.  The  sensation  of  heat, 
both  subjective  and  objective,  naturally  suggested  the  use  of 
this  remedy.  The  application  of  cold  to  an  inflamed  bone  or 
joint  superficially  located  is  of  benefit  during  the  early  stage 
of  inflammation,  at  a  time  when  exudation  and  transudation 
are  only  beginning  and  the  capillary  vessels  are  dilated  and 
only  partially  obstructed.  Tubercular  inflammation,  as  it  affects 
bones  and  joints,  is  a  chronic  process,  made  up  of  successive  at- 
tacks of  acute  exacerbations,  of  shorter  or  longer  duration  and 
greater  or  lesser  intensity.  Cold,  when  applied  during  these 
acute  attacks,  becomes  a  valuable  remedial  agent  (1)  by  pro- 
ducing contraction  of  the  small  blood-vessels  ;  (2)  by  producing 
at  least  an  inhibitory  effect  upon  the  tubercle  bacilli  in  the 
inflamed  tissues.  The  contraction  of  blood-vessels,  -which  takes 
place  under  the  application  of  cold,  has  a  tendency  to  clear  the 
stagnated  capillaries  of  their  surplus  contents  and  to  prevent 
further  mural  implantation  of  bacilli  or  infected  leucocytes. 
Microbes  in  the  tissues  can  only  multiply  at  a  certain  tempera- 
ture, and  if  this  can  be  kept  at  a  point  low  enough  to  prevent 
their  increase,  without  injury  to  the  tissues,  by  the  prolonged 
application  of  cold,  this  agent  fulfills,  at  least  in  part,  one  of 
the  causal  indications  in  the  treatment  of  inflammation.  If, 
however,  stasis  has  already  taken  place  in  the  capillaries  first 
affected,  the  application  of  cold  will  prove  harmful,  as  it  in'tf 
tend  to  prevent  the  formation  of  an  adequate  collateral  circula- 
tion. This  agent  will  therefore  prove  beneficial  in  the  treat- 
ment of  tubercular  bone  and  joint  disease  during  its  early 


LOCAL    TREATMENT.  209 

stages  and  during  the  interval  of  acute  exacerbations.  Em- 
ployed at  such  times,  its  use  is  often  followed  by  diminution  of 
pain,  swelling,  and  tenderness,  and  initiates  a  process  of  repair. 
If  its  use  is  not  followed  within  a  short  time  by  improvements 
such  as  have  been  enumerated  it  is  evident  that  the  proper  in- 
dications are  not  present  in  the  case,  and  its  further  use  should 
be  dispensed  with.  When  it  appears  desirable  to  resort  to  the 
use  of  cold,  this  remedy  should  be  applied  .in  the  form  of  au 
ice-bag.  The  part  to  which  the  ice-bag  is  to  be  applied  can  be 
covered  with  several  layers  of  a  wet  towel,  as,  otherwise,  the 
prolonged  use  of  the  direct  application  of  ice  may  not  secure  the 
comfort  desired  and  may  endanger  the  superficial  circulation. 
The  sensations  of  the  patient  can  be  accepted  as  a  safe  guide  as 
to  the  degree  of  cold  to  be  used  and  the  length  of  time  it  should 
be  continued. 

Antiseptic  Fomentations.  —  If  cold  applications  are  not 
agreeable  to  the  patient,  or  if  they  are  not  indicated  by  the  loca- 
tion of  the  disease  or  the  stage  of  the  inflammatory  process, 
warm  fomentations  can  often  be  substituted  for  them  with 
benefit  to  the  patient  and  to  favor  the  reparative  process.  Ex- 
ternal heat  stimulates  the  peripheral  capillaries  and  relieves 
internal  congestions,  and^  in  doing  so  acts  favorably  on  a  deep- 
seated  tubercular  focus  in  a  bone  or  joint.  The  old-fashioned 
filthy  poultice  of  flaxseed,  slippery  elm,  bread  and  milk,  and  the 
many  unmentionable,  disgusting  substances  that  have  been  used 
for  centuries  in  the  treatment  of  localized  inflammation,  have 
no  longer  a  place  among  the  resources  of  the  modern  aseptic  sur- 
geon. The  common  poultice  is  a  hot-bed  for  pathogenic  bacteria, 
«n<L  us  xii'-li,  it  should  be  discarded.  The  surface  to  which  a 
fomentation  is  to  be  applied  should  be  thoroughly  cleansed  with 
warm  water  and  potash  soap.  Priesnitz's  ordinary  local  hydro- 
pathic pack  answers  often  an  excellent  purpose  in  relieving  pain 
and  in  stimulating  the  reparative  process  around  a  tubercular 
focus.  A  thick  compress  wrung  out  of  hot  water  is  made  to 
envelop  the  limb  for  some  distance  beyond  the  part  affected  or 


210  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

to  cover  the  inflamed  area  in  other  parts,  and  heat  and  moisture 
are  retained  by  covering  it  with  some  impermeable  substance 
such  as  oiled  silk,  thin  rubber  sheeting,  or  gutta-percha  tissue, 
and  the  dressing  is  retained  by  an  appropriate  bandage.  A*  a 
certain  quantity  of  medicinal  substances  held  in  solution  and 
applied  to  the  cutaneous  surface  for  a  long  time  reaches  ilic 
tissues  by  absorption  through  the  skin,  it  is  advisable  to  apply 
antiseptic  solutions  in  place  of  simple  water  in  the  treatment  of 
a  focalized  infective  inflammation,  in  the  hope  that  even  small 
quantities  of  the  antiseptic  substance  employed  may  exert  an 
inhibitory  effect  on  the  microbes  residing  in  the  tissues.  Only 
such  substances  and  solutions  of  such  strength  should  be 
used  for  this  purpose  that  their  prolonged  application  will  not 
be  attended  by  danger  of  producing  intoxication.  In  the  treat- 
ment of  tubercular  inflammation  of  bones  and  joints  by  hot 
fomentations,  I  would  recommend  iodine-water,  a  solution  of 
corrosive  sublimate  1  to  5000,  carbolic  acid  1  to  100,  or 
boric  acid  5  to  100.  Absorption  through  the  skin  of  the 
antiseptic  substance  used  will  have  a  direct  influence  in  dimin- 
ishing the  intensity  of  the  primary  cause  which  produced  the 
inflammation,  and  prepares,  in  an  admirable  manner,  the  field 
for  any  operation  which  may  become  necessary  in  the  future. 

Massage. — This  local  measure  is  more  applicable  in  the 
treatment  of  some  of  the  results  than  the  tubercular  inflamma- 
tion itself.  Tuberculosis  of  bones  and  joints  is  always  attended 
by  atrophy  of  the  muscles  of  the  affected  limb,  and  in  the  case 
of  joints  even  the  most  favorable  termination  almost  always 
leaves  more  or  less  stiffness  in  the  joint,  and  it  is  in  the  cor- 
rection of  these  two  consequences  of  the  tubercular  affection 
that  massage  yields  satisfactory  results.  Massage  of  a  joint  (he 
seat  of  an  active  tubercular  inflammation  aggravates  the  lo<-<il 
conditions  and  might  become  a  direct  cause  of  metastatic  foci  in 
other  organs.  After  the  inflammatory  symptoms  have  subsided, 
systematic  massage,  scientifically  practiced,  is  an  exceedingly 
important  and  valuable  therapeutic  resource.  It  stimulates  the 


LOCAL   TREATMENT.  211 

surrounding  vessels  to  increased  action,  and  exerts  a  potent  in- 
fluence in  restoring  the  normal  circulation  in  the  affected  capil- 
lary vessels,  promotes  absorption  and  increases  nutrition  of  the 
wasted  atrophic  muscles.  The  masseur  should  be  instructed  to 
apply  some  absorbent  preparation  before  the  frictions  and 
manipulations  are  made,  as  the  endermic  use  of  absorbent  drugs 
in  this  manner  will  increase  the  efficacy  of  the  treatment.  A 
drachm  of  potassic  iodide  or  half  a  drachm  of  iodoform  to  an 
ounce  of  lanolin  or  sanitas  will  be  an  excellent  preparation  for 
this  purpose.  Cold  and  hot  douches,  passive  and  active  motion, 
combined  with  massage,  will  often  expedite  a  cure  by  increasing 
the  circulation  and  nutrition  of  the  part  or  limb. 

Counter-irritation. — The  idea  that  an  inflammation  arti- 
ficially produced  in  the  vicinity  of  an  inflamed  bone  or  joint 
would  exert  a  curative  influence,  that  prevailed  for  such  a  long 
time  and  received  the  support  of  the  most  prominent  surgeons, 
is  no  longer  tenable.  Cauterization,  blistering,  seton,  moxa, 
and  the  application  of  tincture  of  iodine  in  full  strength,  and 
other  irritants  are  not  only  useless  in  the  treatment  of  bone  and 
joint  tuberculosis,  but  positively  harmful.  Anything  which 
destroys  the  continuity  of  the  skin  over  a  tubercular  focus  adds 
to  the  suffering  of  the  patient  and  may  create  an  infection-atrium 
for  secondary  infection.  Mercurial  inunctions,  of  value  in  the 
treatment  of  syphilitic  bone  and  joint  affections,  are  positively 
contra-indicated  in  the  treatment  of  tubercular  lesions.  As 
patients  and  their  friends  always  entertain  the  highest  opinion 
of  the  utility  of  external  applications,  it  is  often  necessary,  in 
order  to  retain  their  confidence,  to  prescribe  an  absorbent  non- 
irritating  ointment  to  prevent  them  from  passing  into  the  hands 
of  charlatans  before  the  time  has  arrived  to  resort  to  more 
effective  and  radical  measures. 

Electricity. — Neither  the  constant  nor  the  faradic  current 
can  have  a  curative  effect  on  the  tubercular  lesion,  but  both  are 
useful  in  the  treatment  of  one  of  the  most  constant  remote 
effects  of  tubercular  processes  in  bones  and  joints, — muscular 


212  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

atrophy.  The  use  of  electricity  must,  therefore,  be  reserved  for 
cases  in  which  the  tubercular  process  lias  been  arrested  spon- 
taneously or  by  appropriate  treatment,  for  the  purpose  of  bet- 
tering the  functional  result.  This  part  of  the  treatment  should 
not  be  entrusted  to  the  patient  or  non-professional  persons,  but 
should  be  carried  out  by  the  attending  physician  or  some  person 
fujly  competent  under  his  supervision.  Massage  and  electricity 
are  indicated  in  the  same  class  of  cases,  and  one  should  be 
supplementary  to  the  other. 

Tapping  of  Joint. — Saxtorph  ("  Kasuistiske  Meddelelser  fra 
Frederiks  Hospital  chirurgiske  Afdeling.  Uet.  Kgl.  medicinske 
Selskab.  Forhandl.  Bibliothek  f.  Lager,"  B.  xx,  S.  167)  was  one 
of  the  first  to  resort  to  the  trocar  as  a  therapeutic  resource  in 
the  treatment  of  chronic  synovitis  with  effusion.  He  evacuated 
the  joint  with  an  ordinary  trocar,  after  which  he  immobilized 
the  joint  and  enforced  rest  in  bed  for  two  weeks.  He  reported 
thirteen  cases  treated  by  this  method,  and  had  never  observed 
any  unpleasant  consequences  which  could  be  traced  to  the 
operation. 

The  value  of  repeated  tappings  of  hydropic  joints  was 
prominently  brought  to  the  attention  of  the  profession  in  this 
country  by  Bauer,  of  St.  Louis.  ("  Clinical  Lecture  on  Hy- 
drarthos,  Haemato-arthrosis,  and  Perforating  Wounds  of  the 
Knee-Joint."  St.  Louis  Medical  and  Surgical  Journal,  July, 
1870.)  He  spoke  especially  of  the  advantages  pertaining  to 
tapping  for  hydrops  of  the  knee-joint.  Before  puncturing  he 
forced  the  fluid  into  the  upper  recess  of  the  joint  by  bandages 
and  compresses  and  exercised  great  care  in  guarding  against 
the  entrance  of  air  into  the  joint  through  the  cannula  of  the 
trocar.  After  evacuation  of  the  joint  he  applied  compression 
with  graduated  compresses  and  strips  of  adhesive  plaster,  and 
confined  the  limb  upon  a  straight  posterior  splint.  Since  the 
introduction  of  the  aspirator  by  Dieulafoy  this  instrument  has 
partially  displaced  the  trocar  in  the  removal  of  fluid  from  joints, 
and  we  now  speak  of  aspiration  as  well  as  tapping  of  joints. 


LOCAL   TREATMENT.  213 

The  aspirator  gives  greater  security  against  the  entrance  of  air 
than  the  trocar  in  the  hands  of  surgeons  whose  experience  with 
this  kind  of  treatment  is  limited.  With  proper  care,  however, 
this  accident  can  be  prevented  with  certainty  in  using  the  tro- 
car. If,  as  is  now  customary,  the  evacuation  of  a  joint  is  fol- 
lowed by  intra-articular  irrigation  and  medication,  a  trocar  is 
preferable  to  an  aspirator.  Carelessness  in  the  use  of  the  latter 
instrument  is  attended  by  great  danger,  as  it  has  happened  that, 
instead  of  making  aspiration,  air  was  injected  into  the  joint, 
and  in  one  case,  which  has  been  reported,  this  accident  was 
the  cause  of  sudden  death  on  the  operating-table ;  the  injected 
air  undoubtedly  found  its  way  into  the  veins,  and  death  resulted 
from  air-embolism.  In  using  either  of  these  instruments  it  is 
necessary  to  resort  to  strict  antiseptic  precautions  to  guard  effec- 
tually against  secondary  infection.  The  instruments  should  be 
sterilized  by  boiling  or  by  heating  them  sufficiently  by  passing 
them  through  the  flame  of  an  alcohol-lamp.  The  site  for  the 
puncture  must  be  thoroughly  disinfected.  Before  the  puncture 
is  made  the  skin  should  be  drawn  to  one  side,  so  that,  after  the 
removal  of  the  cannula  or  needle,  the  deep  puncture  may  be 
subcutaneous.  The  point  where  the  puncture  is  to  be  made 
should  be  carefully  ascertained  for  each  individual  joint.  As  a 
ride,  a  place  should  be  selected  where  the  joint  is  nearest  to  the 
surface.  In  tapping  the  hip-joint  the  puncture  is  made  at  the 
upper  margin  of  the  great  trochanter,  at  a  point  equidistant 
from  its  anterior  and  posterior  border,  from  where  the  instru- 
ment is  plunged  in  a  downward  and  inward  direction  until  its 
point  has  reached  the  neck  of  the  femur,  when  the  thigh  is 
adducted  and  the  instrument  advanced  until  solid  resistance 
is  again  met  with.  The  knee-joint  is  most  accessible  at  a 
point  corresponding  with  the  upper  recess  of  the  synovial  sac, 
on  the  outer  side,  a  little  above  and  external  to  the  patella.  The 
instrument  should  be  inserted  boldly  until  its  point  is  underneath 
the  patella.  In  tapping  the  ankle-joint  the  foot  should  be  ex- 
tended and  the  puncture  made  at  a  point  anteriorly  corresponding 


214  TUBERCULOSIS   OP   THE   BONES   AND   JOINTS. 

with  the  anterior  border  of  the  external  malleolus,  near  its  base. 
The  spaces  between  the  different  tarsal  bones  are  punctured  in 
places  most  accessible  from  the  external  surface.  The  shoul- 
der-joint can  be  reached  with  equal  ease  from  the  front  and 
from  behind.  The  elbow-joint  is  accessible,  by  the  shortest 
and  most  direct  route,  by  puncturing  at  the  outer  border  of 
the  olecranon  process,  at  a  point  half-way  between  its  base 
and  tip,  entering  the  joint  between  the  head  of  the  radius  and 
outer  condyle  of  femur. 

The  wrist-joint  can  be  tapped  from  the  radial,  ulnar,  or 
dorsal  side,  and  when  the  operation  is  to  be  repeated  it  is 
advisable  to  alternate  between  these  different  places.  In  tu- 
bercular hydrops  the  intra-articular  effusion  is  often  very  copi- 
ous, resulting  in  enormous  distension  of  the  capsule  of  the 
joint,  which,  if  continued  for  any  length  of  time,  must  neces- 
sarily result  in  great  weakening  of  the  joint.  Tapping  or 
aspiration,  under  these  circumstances,  relieves  the  distension 
and  places  the  vessels  in  the  synovial  membrane  in  a  better 
condition  to  perform  their  function  in  the  subsequent  removal 
of  the  inflammatory  product  by  absorption.  If  the  tapping  is 
not  followed  by  iodoformization,  which  is  now  generally  prac- 
ticed in  such  cases,  the  limb  should  be  immobilized  and  rapid 
re-accumulation  of  fluid  prevented  by  uniform,  equable  com- 
pression of  the  joint  by  strips  of  adhesive  plaster  or  carefully 
regulated  pressure  by  a  rubber-webbing  bandage. 


CHAPTER 

TUBERCULIN  TREATMENT. 

SOON  after  Koch  delivered  his  famous  address  at  the  Berlin 
International  Medical  Congress,  he  made  known  the  application 
of  the  chemical  substance  which  was  prepared  in  his  laboratory 
for  the  treatment  of  tuberculosis  (Deutsche  Med.  Wochenschrift, 
November  14,  1890;  extra  edition  Medical  News,  November 
15,  1890).  The  remedy  is  a  brownish,  transparent  liquid, 
which  does  not  require  special  care  to  prevent 
decomposition.  For  use,  this  fluid  must  be  more 
or  less  diluted,  and  the  dilutions  are  liable  to 
undergo  decomposition  if  prepared  with  distilled 
water.  As  bacterial  growths  soon  develop  in 
them  they  become  turbid,  and  are  then  unfit 
for  use.  To  prevent  this  the  diluted  liquid  must 
be  sterilized  by  heat  and  preserved  under  a  cotton- 
wool stopper,  or,  more  conveniently,  prepared 
with  a  J-per-cerit.  solution  of  carbolic  acid.  As 
the  remedy  appears  to  be  weakened  by  frequent 
heating  and  the  admixtuve  of  antiseptics,  it  is 
advisable  to  use  a  freshly-prepared  solution.  The 
instrument  used  for  making  the  injections  is  the 
bacteriological  syringe  devised  by  Koch  which 
has  no  piston,  but  instead  is  furnished  with  a 
rubber  ball.  This  syringe  is  easily  kept  aseptic  by  the  use  of 
absolute  alcohol. 

The  place  chosen  for  the  injection  was  the  skin  of  the  back 
between  the  shoulder-blades  and  the  lumbar  region. 

As  regards  the  effect  of  the  remedy,  a  healthy  guinea-pig 
will  bear  a  subcutaneous  injection  of  2  cubic  centimetres,  and 
even  more,  of  the  liquid  without  being  sensibly  affected ;  but 
in  the  case  of  a  full-grown,  healthy  man  0.25  cubic  centimetre 
suffices  to  produce  an  intense  effect.  A  healthy  person  reacts 

(215) 


FIG.  33.— KOCH'S 
SYRINGE. 


216  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

either  not  at  all  or  scarcely  at  all  when  0.01  cubic  centimetre 
is  used.  A  dose  of  0.01  cubic  centimetre  injected  subcuta- 
neously  into  tubercular  patients  causes  a  severe  general  reaction 
as  well  as  a  local  one.  The  general  reaction  consists  in  an 
attack  of  fever,  which  usually  begins  with  rigors  and  raises 
the  temperature  above  39°,  often  up  to  40°.  and  even  41°  C. 
This  is  accompanied  by  pain  in  the  limbs,  coughing,  great 
fatigue,  and  often  nausea  and  vomiting. 

•4&':  In  several  cases  a  slight  icteroid  discoloration  was  observed, 
and  occasionally  an  eruption  like  measles  on  the  chest  and  neck. 
The  attack  usually  begins  four  or  five  hours  after  the  injection, 
and  lasts  from  twelve  to  fifteen  hours.  Occasionally  it  begins 
later  and  then  runs  its  course  with  less  intensity.  The  febrile 
attack  leaves  the  patient  subjectively  in  a  better  condition  than 
before  the  injection.  The  local  reaction  can  be  studied  to  the 
best  advantage  in  cases  in  which  the  tubercular  affection  is 
visible.  For  instance,  in  cases  of  lupus,  changes  take  place 
which  show  the  specific  antitubercular  action  of  the  remedy  to 
a  most  surprising  degree.  A  few  hours  after  an  injection  into 
the  skin  of  the  back, — that  is,  in  a  spot  far  removed  from  the 
diseased  area  on  the  face  or  elsewhere, — the  lupus  begins  to  swell 
and  to  redden,  and  this  it  does  generally  before  the  initial  rigor. 
During  the  fever  the  swelling  and  redness  increase,  and  may 
finally  reach  a  high  degree,  so  that  the  lupous  tissue  becomes 
brownish  and  necrotic  in  places  where  the  growth  was  sharply 
defined.  After  the  subsidence  of  the  fever,  the  swelling  of  the 
lupous  tissue  gradually  decreases  and  disappears  in  about  two  or 
three  days.  The  lupous  spots  themselves  are  then  covered  by  a 
soft  deposit,  which  filters  outward  and  dries  in  the  air.  The 
growth  then  changes  to  a  crust,  which  falls  off  after  two  or  three 
weeks,  and  which,  sometimes  after  only  one  injection,  leaves  a 
clean,  red  cicatrix  behind.  Generally,  however,  several  injec- 
tions are  required  for  the  complete  removal  of  the  lupous  tissue. 
It  appears  that  the  fluid  injected  possesses  a  special  predilection 
for  tubercular  tissue,  and  upon  which  it  exerts  its  specific  action. 


PLATE  VII. 


FIG.  34. — BACILLI  BEFORE  INJECTION.    (Koch.) 


FIG.  35. — BACILLI  AFTER  INJECTION.    (Koch.) 


TUBERCULIN  TREATMENT.  217 

In  the  treatment  of  tubercular  affections  of  the  glands,  joints, 
bones,  etc.,  by  the  same  method,  the  parts  affected,  a  few  hours 
after  the  injections,  become  more  painful,  swollen,  and  red.  As 
only  tubercular  tissue  and  tubercular  patients  react  after  the  in- 
jection of  an  ordinary  dose  of  lymph,  the  injection  proves  as 
reliable  in  diagnosis  as  useful  in  the  treatment  of  nearly  all 
forms  of  localized  tubercular  processes.  In  tubercular  patients 
subjected  to  this  treatment,  the  effect  of  the  succeeding  injections 
will  show  when  the  primary  cause  of  the  disease  has  been  re- 
moved, or,  at  least,  rendered  harmless. 

Koch  maintains  that  the  remedy  does  not  kill  the  tubercle 
bacilli,  but  the  tubercular  tissue,  and  this  gives  us  clearly  and 
definitely  the  limit  that  bounds  the  action  of  the  remedy.  (Plate 
VII,  Figs.  34  and  35.) 

The  action  of  the  remedy  is  limited  to  living  tubercular 
tissue,  and  it  has  no  effect  on  necrotic  or  caseous  tubercular 
material.  The  fact  that  the  remedy  makes  tubercular  tissue 
necrotic  and  acts  only  on  the  living  tissue  helps  to  explain  the 
circumstance  that  it  cannot  be  administered  safely  in  rapidly 
increasing  doses.  In  the  different  forms  of  surgical  tuberculosis 
uncomplicated  by  advanced  pulmonary  phthisis,  the  treatment 
can  be  commenced  by  injecting  0.1  cubic  centimetre,  the  same 
dose  to  be  repeated  after  a  week  or  two,  continuing  in  the  same 
way  until  the  reaction  becomes  weaker  and  weaker,  and  finally 
ceases  entirely, — an  indication  that  the  process  has  become  com- 
pletely arrested.  Phthisical  patients  reacted  strongly  to  0.002 
cubic  centimetre,  but  gradually  became  tolerant  to  larger 
doses.  The  first  publication  on  the  treatment  of  tubercular 
affections  of  joints  and  bones  by  Koch's  method  was  made  by 
Bergmann  (Journal  American  Medical  Association,  December 
20,  1890),  who  had  tried  it  in  sixteen  cases,  some  of  them  having 
advanced  to  the  formation  of  abscesses  and  fistula.  Some  of 
these,  to  whom  a  first  injection  had  been  applied,  showed  the 
usual  symptoms;  the  joints  were  much  swollen  and  highly 
colored,  and  movement  was  scarcely  possible.  Others  had  been 


218  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

treated  by  repeated  injections.  One  of  these,  who  suffered  from 
pulmonary  phthisis  and  tubercular  inflammation  of  the  knee- 
joint,  was  so  severely  affected  by  the  injections  (intermittent 
pulse,  faintness,  etc.)  that  there  seemed  cause  for  anxiety.  He 
had,  however,  recovered,  and  was  progressing  favorably.  In 
summing  up  the  cases  Bergmann  said  that,  from  the  local  and 
general  symptoms  which  had  already  shown  themselves,  the 
prognosis  was  decidedly  favorable.  Nevertheless,  in  many  cases 
surgical  operations  would  still  be  unavoidable,  as  abscesses  and 
dislocations  could  only  be  cured  by  mechanical  means.  In 
these  cases  it  would  be  of  the  highest  importance  to  guard 
against  relapse  by  the  repetition  of  Koch's  treatment,  and  thus 
both  methods  combined  gave  the  brightest  prospect  of  success. 

E.  Hahn  {Deutsche  Med.  Wocliensclirift,  January  1,  1891) 
reports  59  cases  of  surgical  tuberculosis  subjected  to  Koch's 
treatment.  In  32  of  these  the  treatment  had  advanced  suffi- 
ciently to  show  its  merits;  16  were  considerably,  and  12  appre- 
ciably, benefited;  in  4  no  change  was  perceptible.  In  cases  of 
tubercular  joint  and  bone  disease,  the  results  were  better  when 
sinuses  existed  than  in  others  in  which  there  was  neither  sinus 
nor  surgical  opening.  In  one  case,  in  which  the  knee-joint  was 
resected,  reaction,  which  had  been  very  strong  before  the  opera- 
tion, entirely  ceased  after  it. 

Hans  Schmid  (ibid.)  reports  the  effects  observed  in  sixty 
patients  in  the  Bethany  Hospital  at  Stettin.  The  treatment 
proved  satisfactory,  and  high  hopes  were  entertained  in  regard 
to  the  final  beneficial  results. 

Socm(Carsp  u.  Correspond  enzbhitt  f.  /Schweizerartze,  1891, 
No.  1,  p.  91)  tried  the  method  in  twenty  cases,  and  from  his 
observations  he  was  in  doubt  as  to  the  healing  powers  of  the 
fluid.  He  believes  the  knife  will  still  have  to  be  relied  upon  as 
heretofore,  but  at  the  same  time  he  thinks  there  can  be  no  doubt 
that  the  new  method  will  enable  surgeons  to  operate  with  greater 
certainty  and  with  more  satisfactory  results. 

Lindner    (Deutsclie    Med.    Wocliensclirift,   December    18, 


TUBERCULIN  TREATMENT.  219 

1890)  reports  two  cases  in  which,  although  no  reaction  what- 
ever followed  the  injections,  the  local  condition  was  considerably 
improved.  A  man  who  had  been  operated  on  for  disease  of  the 
elbow-joint,  judged  to  be  of  a  tubercular  nature,  still  suffered 
from  painful  swelling  in  the  joint,  together  with  a  fistula  which 
could  not  be  made  to  heal.  After  several  injections  of  Koch's 
fluid,  though  no  reaction  had  occurred,  the  fistula  closed,  the 
swelling  disappeared,  and  the  movement  of  the  joint  was  restored. 
The  other  patient  was  a  man  who  had  a  large  number  of  fistula 
over  the  sternum  and  considerable  tubercular  lesions  in  the  lungs. 
Injections  even  of  doses  of  3  centigrammes  caused  no  reaction ; 
nevertheless,  at  the  end  of  a  fortnight,  the  greater  number  of 
fistulas  had  healed,  and  the  few  that  remained  the  openings 
scarcely  admitted  the  end  of  the  probe. 

Helferich  (Deutsche  Med.  Woclienschrift,  No.  50,  1890) 
speaks  very  hopefully  of  the  treatment,  of  which  he  says  he 
can  only  compare  it  with  that  of  antisepsis.  He  compares  the 
specific  effect  of  the  fluid  on  tubercle  to  that  of  mercury  and 
iodide  of  potassium  on  syphilis.  In  four  cases  of  hip-joint 
disease  it  was  noticed  that  the  local  pain  caused  by  reaction 
was  less  severe  when  the  ordinary  extension  treatment  was 
employed.  With  regard  to  the  general  reaction,  Helferich 
observed  that  frequently  the  second  and  third  injections  of  the 
same  dose  were  followed  by  a  higher  fever  than  the  first ;  that 
the  interval  between  the  injection  and  the  commencement  of 
reaction  is  longest  after  the  first  injection,  and  becomes  gradu- 
ally less  as  the  treatment  is  continued ;  that  the  highest  degree 
of  temperature  is  most  speedily  reached  after  the  second  and 
third  injections ;  and  that  the  duration  of  the  fever,  after  doses 
of  the  same  strength,  is  shorter  after  several  injections  have 
been  given  than  at  first. 

Verneuil  (Union  Medical,  January  22  and  24,  1891) 
claims  that  an  authentic  and  permanent  cure  by  the  use  of 
Koch's  lymph  has  yet  to  be  recorded ;  temporary  benefit  has 
been  observed  in  a  few  cases ;  serious  complications  arising  in 


220  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

healthy  organs  have  been  frequent,  and  a  very  considerable 
number  of  deaths,  owing  to  aggravation  of  the  local  condition, 
to  lesion  of  healthy  organs,  or  to  fresh  infection  by  the  lymph, 
have  been  reported.  He  maintains  that  it  cannot  be  relied 
upon  as  a  means  of  diagnosis,  and,  owing  to  the  danger  which 
attends  the  local  reaction,  the  degree  of  which  cannot  be  fore- 
seen, it  would,  he  thinks,  be  desirable  to  make  use  of  the 
remedy  as  a  diagnostic  agent  only  if  it  were  actually  indis- 
pensable for  diagnosis,  which,  he  contends,  is  not  the  case. 

Feilchenfeld  ("  Ueber  den  Verlauf  einiger  mit  dem  Koch'- 
schen  Heilmittel  behandelten  Fiille  von  Tuberculose  verschied- 
ener  Organe."  Therap.  Mon.  Hefte,  November,  1890)  made 
the  claim  that  in  a  number  of  cases  of  osteo-arthritis  a  definite 
cure  had  been  effected  by  tuberculin  injections.  Among  the 
more  important  papers  detailing  favorable  experiences  with 
Koch's  lymph  in  the  treatment  of  surgical  tuberculosis  may  be 
mentioned  "  Bericht  iiber  die  Anwendung  des  Koch'schen  Heil- 
mittels  bei  Kranken,"  von  Esmarch  (Deutsche  Med.  Woclien- 
schrift,Nos.  3-4,  1891);  "  Mittheilungen  iiber  das  Koch'sche 
Heiiverfahren,"  H.  von  Burckhardt  (Med.  Corresp.  Elatt  des 
Wiirt.  iirzt.  Landesvereins,  December  18,  1890);  "Das  Koch'- 
sche Heiiverfahren  combinirt  mit  chir.  Eingriffen,"  Sonnenburg 
(Deutsche  Med.  Wocliensclirift^  No.  1,  1891);  "Mittheilungen 
iiber  das  Koch'sche  Heiiverfahren  aus  dem  Kaiser  Franz 
Josef  Kinderspital  in  Prag,"  Ganghofer  u.  Bayer  (Prager  Med. 
Wocliensclirift,  No.  34,  1891);  "Das  Koch'sche  Heiiverfahren 
im  Spital  Miinsterlingen,"  Kappeler  (Correspond enzblatt  fur 
Scliweizeraerzte,  1891). 

At  the  Second  Congress  of  Tuberculosis,  July  27  to 
August  2,  1891,  Arloing,  Rodet,  and  Courmont  presented  a 
communication  on  "  Experimental  Studies  of  the  Properties 
Attributed  to  Koch's  Tuberculin."  In  this  paper  they  gave 
the  results  of  their  own  investigations  concerning  the  three 

O  O 

principal  properties  attributed  to  Koch's  lymph — its  curative 
effect,  its  diagnostic  value,  and  its  prophylactic  properties. 


TUBERCULIN  TREATMENT,  221 

They  found,  as  one  of  its  most  constant  effects,  a  rise  in 
temperature,  which,  however,  is  always  preceded  by  a  pro- 
dromic  stage,  which  seems  to  indicate  that  the  fever  is  not 
produced  directly  by  tuberculin,  but  probably  by  a  phlogistic 
substance,  which  forms  by  the  action  of  tuberculin  on  the  tis- 
sues. They  place  no  absolute  reliance  on  its  diagnostic  value. 
From  a  therapeutic  point  of  view,  these  authors  have  found 
Koch's  lymph  useless  in  the  case  of  bird,  bovine,  or  human 
tuberculosis  in  animals.  Finally,  these  experimenters  attempted 
to  verify  the  assertion  of  Koch,  made  at  the  International  Med- 
ical Congress,  that  the  guinea-pig  was  rendered  immune  to 
tuberculosis  by  treatment  with  tuberculin ;  they  found,  on  'the 
contrary,  that  in  many  cases  these  animals  were  thus  rendered 
much  more  susceptible  to  tubercular  lesions;  iri  ifact,  that  the 
lesions  were  much  more  confluent  and  showed  greater  tendencies 
to  speedy  disintegration. 

The  concluding  remarks  on  tuberculin  treatment  are  taken 
mostly  from  a  paper  on  "  Away  with  Koch's  Lymph !"  which  I 
had  the  honor  to  read  at  a  meeting  of  the  Chicago  Medical 
Society,  May  18,  1891,  and  which  was  published  in  the  Chi~ 
cago  Medical  Recorder,  June,  1891.  In  this  paper  a  brief  his- 
tory and  the  immediate  and  remote  results  of  the  treatment  are 
given  in  53  cases  of  tuberculosis,  of  which  43  were  cases  of 
pulmonary  phthisis  and  10  cases  of  surgical  tuberculosis,  and 
of  the  latter  4  were  cases  of  joint  and  bone  affections.  Only 
the  last  4  cases  will  be  reported  in  full. 

"  When,  six  months  ago,  the  telegraph  operator  at  Berlin 
touched  the  key  of  his  instrument  and  flashed  to  all  parts  of 
the  civilized  world  the  joyful  tidings  that  a  cure  for  tubercu- 
losis had  at  last  been  discovered,  the  people  and  the  profession 
felt  that  the  millennium  in  medicine  had  come.  For  days  and 
weeks  the  public  press  devoted  a  liberal  space  to  telegraphic 
messages,  editorials,  and  interviews  with  medical  men  relative 
to  the  new  treatment.  For  months  the  medical  journals  in  all 
countries  rivaled  each  other  in  bringing  the  latest  reports  from 


222  TUBERCULOSIS    OF   THE    BONES    AND    JOINTS. 

Berlin  and  other  large  medical  centres  in  the  way  of  telegrams, 
correspondence,  editorials,  and  original  contributions. 

"The  first  announcement  of  the  discovery  brought  thou- 
sands of  patients  and  doctors  to  the  German  capital,  the  former 
to  be  cured  of  their  tubercular  disease,  the  latter  to  receive 
instruction  and  to  make  themselves  proficient  in  all  the  details 
of  the  new  treatment.  No  other  event  in  the  world's  history 
ever  attracted  so  much  attention,  and  no  discovery  in  medicine 
or  surgery  ever  found  such  ready  introduction  and  universal 
acceptation.  The  discoverer  —  the  distinguished  Koch,  the 
father  of  bacteriology — had  scored  so  many  victories  on  this 
modern  field  of  research  that  every  word  he  uttered  brought 
conviction.  His  views  were  promptly  adopted  by  the  most 
prominent  physicians  and  surgeons  in  Germany  and  other 
countries,  and  the  new  treatment  was  applied  everywhere,  by 
the  best  men  in  the  profession,  as  fast  as  the  precious  remedy 
could  be  obtained. 

"  Within  a  few  weeks  the  most  enthusiastic  and  encourag- 
ing reports  came  from  scores  of  prominent  clinics  and  large 
hospitals.  Within  a  few  months  volumes  have  been  written 
on  this  subject ;  several  special  works  on  this  treatment  left  the 
press  and  were  translated  into  many  languages.  A  new  journal, 
devoted  exclusively  to  the  treatment  of  tuberculosis  with  Koch's 
lymph,  has  come  into  existence  and  has  a  good  subscription- 
list  from  the  very  start.  It  is  true  that  some  of  the  more  con- 
servative members  of  the  profession  were  a  little  slow  in  accept- 
ing the  new  doctrine  and  practice ;  but  the  large  majority 
followed  the  current  set  in  motion  by  the  great  Koch  and  his 
many  eminent  admirers  and  devoted  followers. 

"  It  was  not  long,  however,  before  the  glowing  accounts  of 
the  results  of  the  new  treatment  of  tuberculosis  came  at  longer 
intervals  and  in  a  more  moderate  tone,  and  were  interspersed 
with  the  reports  of  cases  from  different  parts  of  the  world  in 
which  it  proved  a  complete  failure,  and  not  in  an  inconsiderable 
number  of  cases  it  was  charged  with  having  caused  a  speedy 


TUBERCULIN  TREATMENT.  223 

fatal  termination.  Then  came  the  timely  warning  of  the  veteran 
pathologist,  Virchow,  who  showed,  by  numerous  post-mortem 
examinations  of  patients  who  died  under  this  treatment,  that 
death  was  caused  by  dissemination  of  the  disease  from  a  local 
focus  acted  upon  by  the  lymph.  The  evidences  proving  this 
source  of  danger  have  been  rapidly  accumulating,  and  contributed 
largely  toward  subduing  the  first  enthusiasm  and  limiting  the 
scope  of  administration  of  the  remedy. 

"  The  disastrous  consequences  which  followed  the  use  of 
the  lymph,  perhaps  often  injudiciously  and  recklessly  applied,  in- 
duced a  number  of  medical  societies  to  condemn  its  use,  and  led 
some  of  the  local  governments  to  restrain  its  further  application 
by  legal  enactments. 

"  Enough  time  has  now  elapsed  to  judge  of  the  merits  of 
the  treatment  of  tuberculosis  by  Koch's  lymph,  or,  as  it  is  now 
called,  tuberculin.  It  has  been  put  to  test  in  the  treatment  of 
all  forms  of  tuberculosis. 

"  Surgeons,  physicians,  gynaecologists,  obstetricians,  derma- 
tologists, otologists,  and  ophthalmologists  have  given  the  new 
treatment  a  fair  trial,  and  the  accumulated  experiences  from  all 
these  sources  have  shown,  beyond  all  doubt,  that  its  indiscrimi- 
nate use  is  attended  by  many  immediate  and  remote  dangers, 
and  that  most  cases  in  which  it  appeared  to  prove  beneficial  at 
first  have  relapsed,  and  after  weeks  and  months  were  no  better, 
or  even  worse,  than  when  the  treatment  was  commenced. 

"  Men  who  first  regarded  the  lymph  as  a  specific  in  all  forms 
of  tuberculosis  make  this  claim  no  longer.  Many  who  were 
enthusiastic  in  their  praise  of  what  they  observed  from  the  use 
of  the  remedy  in  the  beginning  have  now  suspended  its  use. 
Hospitals  and  wards  set  aside  for  the  special  treatment  of  patients 
suffering  from  tuberculosis  are  now  deserted.  The  market  is 
overstocked  with  a  supply  of  Koch's  lymph  and  Koch's  syringes. 
Not  only  the  profession  but  the  public  has  become  aware  that 
the  claims  made  for  the  remedy  only  a  few  months  ago  are  un- 
founded. It  is  left  for  Koch  or  some  other  investigator,  in  the 


224  TUBERCULOSIS   OF   THE    BONES    AND   JOINTS. 

future,  to  discover  a  substance  or  agent  which  will  answer  the 
expectations  that  were  ut  first  entertained  for  the  lymph. 

"  Koch's  lymph  has  been  a  deceptive  bubble  which,  for  a 
short  time,  commanded  the  attention  and  admiration  of  the  whole 
world,  but  which  has  been  ruthlessly  pricked  by  the  critical 
scalpel  in  the  hands  of  the  father  of  modern  pathology.  The 
treatment  of  tuberculosis  with  Koch's  lymph  and  the  numerous 
substitutes  which  have  recently  been  forced  on  the  attention  of 
the  profession  will  soon  be  only  a  matter  of  history.  My 
'Away  with  Koch's  Lymph!'  is  based  upon  my  own  observa- 
tions made  at  the  Milwaukee  Hospital  during  the  last  four 
months'  service  in  that  institution  prior  to  my  removal  to  this 
city.  The  material  is  not  large,  but  the  careful  observations 
made  entitle  me  to  give  a  positive  opinion  and  warn  others 
against  further  experimentation  with  this  remedy. 

"  The  lymph  first  used  I  received  through  the  courtesy  of 
Dr.  J.  S.  Billings,  of  Washington,  and  when  this  was  exhausted 
I  received-  an  abundant  supply'direct  from  Dr.  Libbcrtz,  through 
the  influence  of  my  distinguished  friend,  Professor  von  Esmarch. 
The  tubercular  nature  of  the  lesions  in  all  cases  that  came 
under  my  own  care,  if  any  doubt  existed  in  this  regard,  was 
established  by  microscopical  examination  and  search  for  the 

bacillus. 

"TUBERCULOSIS  OF  JOINTS  AND  BONES. 

"It  has  been  claimed  by  a  number  of  eminent  surgeons  that 
in  the  absence  of  caseous  foci  and  sequestra  tubercular  joints 
are  amenable  to  successful  treatment  by  lymph  injections,  and 
that  in  a  fair  percentage  of  cases  not  only  a  cure  can  be  effected, 
but  a  perfect  functional  result  obtained.  The  same  authorities 
also  maintained  that,  in  the  event  the  disease  had  advanced  to 
the  formation  of  caseous  deposits,  or  sequestration,  the  same 
treatment,  by  limiting  the  extension  of  the  tubercular  process, 
would  place  the  parts  in  a  more  favorable  condition  for  subse- 
quent successful  operative  interference.  Although  my  experi- 
ence with  Koch's  lymph  in  this  class  of  cases  has  been  limited 


TUBERCULIN  TREATMENT.  225 

to  four  cases,  it  has  taught  me  that  neither  of  these  claims  are 
well  founded. 

'•'•Case  V.  Synovial  Tuberculosis  of  Knee- Joint ;  Intra-artic- 
ular  Injection  of  Iodoform  Emulsion  Followed  by  Koch's  Treat- 
ment.— Maria  Gierswska,  aged  18,  born  in  Poland,  housemaid, 
came  under  my  care  at  the  Milwaukee  Hospital,  January  11, 
1891.  No  hereditary  tendency  to  tuberculosis  in  the  family. 
Patient  is  fairly  well  nourished,  but  somewhat  anaemic.  She 
has  been  a  servant-girl  for  several  years  and  was  required  to 
do  a  great  deal  of  scrubbing,  and  to  this  part  of  her  work  she 
attributed  a  pain  in  the  right  knee-joint,  which  made  its  first 
appearance  about  two  years  ago.  The  pain  was  worse  at  night, 
but  did  not  prevent  her  from  following  her  occupation  until  six 
months  ago.  At  that  time  she  noticed  that  the  joint  was 
swollen  and  tender  on  pressure.  The  swelling  increased  rapidly 
in  size  and  the  movements  of  the  joint  became  impaired.  Ex- 
amination of  the  joint  revealed  the  presence  of  a  copious 
effusion,  with  thickening  of  the  capsule.  No  circumscribed 
points  of  tenderness  over  epiphysial  extremities  of  the  tibia  and 
femur.  Patient  can  walk  without  the  aid  of  crutches. 

"On  January  12th  the  joint  was  aspirated  and  six  ounces 
of  synovial  fluid,  in  which  small  fibrinous  shreads  were  sus- 
pended, was  removed,  after  which  an  mtra-articular  injection 
of  a  10-per-cent.  emulsion  of  iodoform  in  glycerin  was  made. 
The  patient  was  allowed  to  use  the  limb.  In  the  evening  the 
temperature,  which  had  been  normal  before  the  injection  was 
made,  rose  to  102.8°  F.,  but  was  again  found  normal  the  next 
day.  At  the  end  of  forty-eight  hours  the  joint  was  swollen  as 
much  as  before  the  aspiration.  On  January  17th  aspiration  and 
injection  were  repeated.  No  decided  improvement  had  taken 
place  when  the  tuberculin  treatment  was  commenced,  January 
22d.  The  highest  temperature  produced  by  the  first  injection 
was  reached  at  the  end  of  two  hours.  On  the  following  day  the 
swelling  had  increased,  the  capsule  was  tense,  and  the  joint 
tender  and  much  more  painful  than  after  the  iodoform  injections. 


15 


226 


TUBERCULOSIS   OF    THE   BONES    AND    JOINTS. 


The  injection  of  six  milligrammes  of  tuberculin,  made  January 
26th,  was  followed,  at  the  end  of  twelve  hours,  by  a  tempera- 
ture of  105.8°  F., — the  highest  temperature  recorded  in  this 
case. 

"  The  patient  complained  of  headache  and  pain  in  the  region 
of  the  stomach  and  spleen,  attended  by  diarrhoea. 


Number 
of 
Injections. 

Date. 

Dose  in 
Milli- 
grammes. 

Temperature 
before 
Injection. 

Temperature 
during 
Reaction. 

Temperature 
after 
Reaction. 

Pulse  before 
and  during 
Reaction. 

1 

Jan.  22 

2 

96.6 

100.8 

100 

80       90 

2 

23 

4 

100 

103 

99 

96     112 

3 

25 

2 

99 

102.2 

99 

70    106 

4 

26 

6 

99 

1058 

99 

84    144 

5 

28 

5 

99 

105 

100.4 

100    144 

6 

Feb.    3 

6 

98 

105 

99 

82    140 

7 

5 

2* 

99 

100.4 

99.2 

96    100 

8 

7 

3 

99 

99.8 

99 

76      86 

9 

10 

6 

98.2 

103 

98 

76    108 

10 

14 

6 

98 

99 

98 

74      84 

11 

19 

5 

98 

99.4 

98.4 

72      90 

12 

21 

6 

98.4 

99.4 

98.4 

76      80 

13 

24 

6 

98.4 

99.6 

98 

72      96 

"  The  local  and  general  reactions  in  this  case  were  pro- 
nounced, but  both  subsided  gradually  during  the  treatment. 
While  in  the  beginning  of  the  treatment  the  temperature  rose 
to  nearly  106°  F.,  the  last  injection  of  six  milligrammes  was 
followed  by  only  a  little  more  than  one  degree  of  rise  in  tempera- 
ture. During  the  time  the  patient  received  this  treatment  she 
lost  much  in  flesh,  and  became  very  anaemic.  She  left  the  hos- 
pital February  26th,  and  at  that  time  the  joint  was  not  much 
swollen,  and  I  confidently  expected  a  permanent  improvement. 
She  returned  in  two  weeks,  when  the  effusion  had  returned  to 
about  the  same  extent  as  when  the  treatment  was  commenced. 
As  I  had  lost  faith  in  the  Koch  remedy  in  the  treatment  of  this 
class  of  tuberculosis,  I  returned  to  the  treatment  by  intra-articular 
injections  of  iodoform. 

"  Case  VI.  Tuberculosis  of  Left  Knee- Joint. — William  Gabl, 
30  years  of  age,  laborer,  became  an  inmate  of  the  Milwaukee 


TUBERCULIN    TREATMENT. 


227 


Hospital,  March  9,  1891.  No  history  of  tuberculosis  in  his 
family.  Had  been  in  good  health  until  nearly  a  year  ago,  when, 
without  injury  or  any  other  apparent  cause,  he  was  taken  with 
a  pain  in  the  left  knee-joint,  and  in  less  than  twelve  hours  it  be- 
came enormously  swollen  and  exceedingly  painful.  He  was 
forced  to  abandon  his  work  and  seek  rest,  which  in  a  few  days 
brought  about  a  marked  improvement ;  the  swelling  disappeared 
almost  completely,  and  the  slight  pain  and  soreness  in  the  joint 
which  then  existed  did  not  prevent  him  from  following  his  oc- 
cupation. From  this  time  on,  however,  the  knee  was  never 
entirely  well,  a  number  of  slight  attacks  similar  to  the  first  oc- 
curring during  the  summer  months.  Since  November  he  has 
been  unable  to  work ;  the  swelling  remained  permanently,  being 
most  marked  at  the  upper  recess  of  the  synovial  sac  and  on  each 
side  of  the  patella.  The  pain  has  never  been  severe  when  the 
limb  is  at  rest,  and  until  recently  the  patient  has  been  able  to 
walk  without  the  aid  of  crutches. 

"  On  admission,  the  patient  was  anaemic  and  had  lost  about 
twenty-five  pounds  in  weight  during  his  illness.  A  physical 
examination  of  the  chest  yielded  a  negative  result ;  the  left 
limb  is  atrophic;  the  swelling  of  the  knee-joint,  which  is  con- 
siderable, appears  to  be  due  entirely  to  thickening  of  the  syno- 
vial membrane,  there  evidently  being  no  effusion  in  the  joint; 
patient  can  flex  and  extend  leg  nearly  as  well  as  the  opposite 
one.  The  temperature  was  normal  before  the  first  injection  was 
given,  but  within  six  hours  the  thermometer  registered  104.7°  F. 
in  the  axilla. 


Number 
of 

Date. 

Dose  in 
Milli- 

Temperature 
before 

Temperature 
during 

Temperature 
after 

Pulse  before 
and  during 

Injections. 

grammes. 

Injection. 

Reaction. 

Reaction. 

Reaction. 

1 

Mar.    9 

2 

98.4 

104.7 

98.2 

81     108 

2 

"    12 

2 

98.2 

101.8 

98.4 

78      96 

3 

"    16 

2 

99 

102.3 

98 

66      84 

4 

"     21 

2 

97.8 

99.6 

97.8 

72      90 

5 

"    25 

2 

99 

99.9 

99 

76      80 

228  TUBERCULOSIS   OF   THE    BONES    AND    JOINTS. 

"The  local  reaction  was  prompt  after  every  injection,  con- 
sisting of  increased  swelling,  pain,  and  tenderness.  After  the 
fourth  injection  the  physical  signs  pointed  to  the  existence  of  a 
moderate  effusion  in  the  joint.  During  the  fehrile  reaction  the 
patient  suffered  always  more  or  less  from  headache,  backache, 
and  pain  in  the  region  of  the  spleen.  As  the  general  reaction 
appeared  to  have  nearly  ceased  after  the  fifth  injection,  the 
Koch  treatment  was  suspended  to  ascertain  its  ultimate  effect 
upon  the  local  lesions.  As,  a  week  later,  no  perceptible 
improvement  had  taken  place,  the  joint  was  aspirated  and 
about  three  ounces  of  a  synovial  fluid,  in  which  minute 
fibrin ous  flocculi  were  suspended,  removed,  and  an  ounce  of 
a  10-per-cent.  iodoform  emulsion  injected.  The  Brims  treat- 
ment is  being  continued  with  a  fair  prospect  of  an  ultimate 
recovery. 

"  Case  VII.  Tuberculosis  of  the  Hip-Joint. — Maggie  Mc- 
Dermott,  aged  15,  was  admitted  to  the  Milwaukee  Hospital,  Feb- 
ruary 28,  1891,  to  be  treated  for  an  affection  of  the  left  hip-joint. 
Her  father  died  of  pulmonary  tuberculosis  five  years  ago.  With 
the  exception  of  the  usual  diseases  incident  to  childhood,  the 
patient  considered  herself  in  good  health  until  a  year  ago,  when 
she  was  taken  with  a  pain  in  the  region  of  the  left  hip-joint. 
From  that  time  on  she  has  walked  with  a  decided  limp,  but 
continued  her  work  as  a  servant-girl  until  a  few  months  ago. 
The  pain  was  always  worse  at  night  and  after  undergoing  un- 
usual exertion.  The  greatest  pain  is  referred  to  the  region  in 
front  of  the  hip-joint,  but  at  times  she  complains  also  of  a  pain 
about  the  inner  aspect  of  the  knee-joint  on  the  same  side.  Her 
general  health  is  not  much  impaired.  . 

"  An  examination  of  the  hip-joint  reveals  all  the  character- 
istic signs  and  symptoms  of  tubercular  synovitis  following  a 
primary  focus  in  the  neck  of  the  femur.  Extension  was  made 
by  weight  and  pulley ;  at  the  same  time  she  was  subjected 
to  Koch's  treatment,  with  results  shown  in  the  accompanying 
table : — 


TUBERCULIN    TREATMENT. 


229 


Number 

Dose  in 

Temperature 

Temperature 

Temperature 

Pulse  before 

of 

Date. 

Milli- 

before 

during 

after 

and  during 

Injections. 

grammes. 

Injection. 

Reaction. 

Reaction. 

Reaction. 

1 

Mar.    2 

2 

99 

100.1 

98 

78       92 

2 

5 

4 

98 

1033 

99.6 

80    102 

3 

12 

4 

99 

103.5 

100.4 

90    112 

4 

16 

4 

98.4 

100.6 

99 

84    100 

5 

21 

4 

99 

101 

98.4 

84      92 

6 

23 

4 

97.4 

99.4 

99.6 

80    108 

7 

Apr.    3 

4 

98.2 

100 

994 

92    104 

8 

"      6 

4 

98 

100 

98.2 

94    100 

"  The  injections  until  toward  the  last  always  were  followed 
by  an  aggravation  of  the  local  symptoms,  which  usually  lasted 
until  the  end  of  twenty-four  or  thirty-six  hours.  Rest  in  bed 
and  extension  had  a  prompt  effect  in  diminishing  the  pain  and 
tenderness,  but  the  tuberculin  injections  appeared  to  have  no 
influence  in  arresting  the  progress  of  the  disease,  and  had  to  be 
abandoned,  as  the  patient's  general  condition  had  undergone  a 
decided  change  for  the  worse  since  their  use  had  been  com- 
menced. 

"OTITIS   MEDIA    TUBERCULOSA. 

"  Case  VIII.  Pulmonary  and  Laryngeal  Tuberculosis  ;  T\(r 
berculosis  of  Middle  Ear  on  Both  Sides,  and  of  the  Mastoid 
Process  on  the  Right  Side. — Charles  W.  Mueller,  aged  35,  Ger- 
man, farmer  by  occupation,  came  under  my  care  at  the  Milwau- 
kee Hospital,  December  10,  1890.  Tuberculosis  is  hereditary 
in  his  family,  and  he  gives  a  history  of  pulmonary  tuberculosis 
dating  back  for  a  year  and  a  half.  About  six  months  ago  he 
became  hoarse,  a  symptom  which  gradually  increased  in  severity 
until  he  came  to  the  hospital,  when  his  voice  was  a  mere  whis- 
per. Two  months  later  his  ears  became  affected,  the  first  in- 
dication of  this  trouble  being  a  roaring,  buzzing  noise,  attended 
by  slight  pain  and  followed  by  increasing  deafness.  The  patient 
is  considerably  emaciated,  but  his  appetite  and  digestion  have 
been  good.  Examination  of  the  chest  reveals  extensive  infiltra- 
tion of  the  right  apex  of  the  lung,  with  a  number  of  small 
cavities.  The  laryngoscope  shows  numerous  nodules  at  the 


230 


TUBERCULOSIS   OF   THE    BONES   AND   JOINTS. 


base  of  the  epiglottis  and  upon  the  vocal  cords,  cedematous 
infiltration,  and  at  some  points  minute  foci  of  caseation  and 
ulceration ;  drum  of  the  ear  on  both  sides  perforated  and  covered 
with  fungous  granulations ;  on  the  right  side  over  the  mastoid 
process,  and  a  considerable  distance  above  and  behind  it,  the 
skin  is  reddened  and  undermined  by  an  extensive  abscess. 

"  The  abscess  was  incised  and  its  interior,  which  was  lined 
with  a  thick  layer  of  granulation  tissue,  was  scraped  out  with  a 
sharp  spoon,  and  after  thorough  irrigation  was  tamponed  with 
iodoform  gauze.  Almost  the  entire  external  surface  of  the 
mastoid  process  was  denuded  of  periosteum.  Granulations 
taken  from  the  interior  of  the  abscess  and  from  the  external 
ear,  examined  under  the  microscope,  contained  numerous  tu- 
bercle bacilli.  The  external  ear  on  both  sides  was  disinfected, 
iodoformized,  and  loosely  packed  with  absorbent  cotton.  Under 
this  treatment  some  improvement  was  noticeable  until  the  tuber- 
culin treatment  was  initiated.  This  patient  received  the  first 
dose  of  Koch's  lymph  administered  in  the  Milwaukee  Hospital. 
Gradually  increasing  doses  were  given  until  the  maximum  dose, 
25  milligrammes,  was  reached,  as  both  the  local  and  general  reac- 
tions were  not  well  marked.  As  soon  as  the  dose  exceeded  10 
milligrammes  a  diarrhoea  set  in  which  it  was  found  difficult  to 
control,  and  which  greatly  reduced  the  strength  of  the  patient. 


Number 
of 

Date. 

Dose  in 
Milli- 

Temperature 
before 

Temperature 
during 

Temperature 
after 

Pulse  before 
and  during 

Injections. 

grammes. 

Reaction. 

Reaction. 

Reaction. 

Reaction. 

1 

Jan.  21 

2 

99 

102.2 

98.6 

84       96 

2 

23 

4 

98 

101 

99 

80     100 

3 

25 

6 

98 

100.8 

98.4 

94     100 

4 

27 

10 

98 

102 

99.2 

86     106 

•      5 

29 

15 

97.2 

102.6 

98 

82      98 

6 

Feb.    2 

18 

98.7 

101.4 

98.2 

86      90 

7 

5 

20    . 

98.4 

1028 

98.8 

82      94 

8 

7 

20 

99.3 

1006 

99.2 

88    104 

9 

9 

25 

98.6 

102.2 

98.4 

84    102 

"  During  this  treatment  the  patient  lost  his  appetite,  which, 
in  addition  to  the  exhausting  diarrhoea,  contributed  largely  to 
the  rapid  loss  of  flesh  and  strength.  He  left  the  hospital 


TUBERCULIN  TREATMENT.  281 

March  12th,  and  died  a  few  weeks  later.  I  have  no  doubt  that 
the  lyrnph  treatment  shortened  his  life  a  number  of  weeks.,  and 
perhaps  months. 

"Results  of  Tuberculin  Treatment  in  Forty-three  Cases  of 
Pulmonary  Phthisis. — The  injections  were  made,  as  a  rule, 
every  other  day,  in  order  to  ascertain  the  full  extent  of  the 
local  and  general  reaction  following-  each  dose  of  tuberculin. 
The  first  dose  never  exceeded  1  milligramme,  and  in  grave 
cases  the  treatment  was  commenced  with  one-half  of  this 
quantity.  The  dose  was  never  increased  if  the  temperature 
during  the  reaction  following  it  rose  to  101°  F.,  and  if  this 
result  was  reached  in  many  cases  the  dose  was  diminished  or 
the  interval  between  the  injections  increased.  It  is  therefore 
probable  that  in  grave  cases  the  unfavorable  symptoms  follow- 
ing the  injections  were  not  so  much  due  to  the  action  of  the 
tuberculin  as  to  the  intrinsic  tendencies  of  the  disease  to  aggra- 
vation. It  is,  however,  an  entirely  different  matter  in  the  mild 
cases,  in  which,  in  spite  of  a  careful  increase  of  the  dose,  the 
local  and  general  symptoms  underwent  a  rapid  change  for  the 
worse,  as  in  such  cases  the  unfavorable  results  must  be  attrib- 
uted to  the  action  of  the  tuberculin,  and  not  to  the  intrinsic 
tendencies  of  the  disease.  The  whole  number  of  cases  treated 
by  tuberculin  injections  at  the  Milwaukee  Hospital  during  the 
months  of  January,  February,  March,  and  April  is  forty-three, — 
thirty-two  males  and  eleven  females.  For  the  sake  of  convenience, 
these  can  be  divided  into  mild,  medium,  and  grave  cases. 

Mild  cases,  8  males  and  4  females, 12 

Medium  cases,  10  males  and  2  females 12 

Advanced  cases,  14  males  and  5  females,  .        .        .        .19 

43 

Died  in  the  hospital,  1  male  and  1  female,  ...  2 
Aggravation  of  all  the  symptoms  daring  treatment: — 

14  males  and  8  females, 22 

No  improvement,  5  males  and  1  female,  ....  6 
Improved,  10  males  and  1  female,  .....  11 
Apparently  cured,  2  males,  .  .  .  «  .  .2 
Died, .  .  .  .  J! 

43 


232  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

Died  soon  after  leaving  the  hospital: — 

4  males  and  2  females, 6 

Of  the  mild  cases  unfavorably  affected  by  the  treatment: — 
1  male  and  3  females,    .        .        .        ...        .        .4 

Of  the  mild  cases  improved,  4  males  and  1  female,  .         .       5 
Of  the  mild  cases  apparently  cured,  2  males,   ...      2 

11 

"  The  two  cases  that  were  apparently  cured  belonged  to  the 
mild  type  of  the  disease ;  no  such  result  was  obtained  in  any 
of  the  thirty-one  cases  belonging  to  the  medium  or  advanced 
form  of  the  disease.  In  one  of  the  cases  that  was  apparently 
cured  the  sputum  contained  no  bacilli,  and  in  the  other  there 
was  no  expectoration ;  consequently,  some  doubt  must  remain 
as  to  the  tubercular  nature  of  the  pulmonary  affection. 

"  In  the  cases  of  medium  gravity  the  result  of  the  treatment 
was  as  follows  : — 

Aggravated,     -..        .        ,. 5 

Not  improved, .2 

Improved,    . 5 

12 

In  the  grave  cases  the  treatment  was  followed  by  serious 
results  in        ...'......     12 

By  no  improvement  in 3 

By  temporary  improvement  in 2 

By  death  in 2 

19 

"GENERAL    REMARKS    ON    TUBERCULIN    TREATMENT. 

"Diagnostic  Value  of  Tuberculin. — Great  diversity  of  opinion 
prevailed  for  a  long  time  as  to  the  diagnostic  value  of  tuberculin. 
The  first  reports  of  the  use  of  this  substance  were  unanimous 
in  attributing  to  it  positive  diagnostic  value.  It  Avas  claimed 
that  reaction  only  occurred  in  tubercular  patients  by  the  spe- 
cific action  of  the  lymph  on  tubercular  tissue,  and  that  the 
absence  of  increase  of  temperature  after  injection  of  the  lymph 
decided  the  non-tubercular  nature  of  the  affection. 

"  Leyden,  Quincke,  Ebstein,  Weber,  and  Biermer  main- 
tained that  the  absence  or  presence  of  reaction  after  the  use  of 


TUBERCULIN  TREATMENT.  233 

tuberculin  must  not  be  regarded  as  absolute  proof  of  the 
existence  or  non-existence  of  tubercular  disease  in  all  cases. 

"  Schultze,  Finkler,  Guttmann,  Schreiber,  Lichtheim,  and 
Rumpf  had  great  faith  in  the  diagnostic  value  of  the  use  of 
tuberculin  in  tuberculosis  of  the  internal  organs.  The  same 
discrepancy  of  opinion  existed  among  surgeons  as  to  the  value 
of  tuberculin  injections  in  the  differential  diagnosis  of  surgical 
tubercular  and  non-tubercular  lesions. 

"  Bergmann  relied  on  the  reaction  following  the  use  of 
tuberculin  in  differentiating  between  tuberculosis  on  the  one 
hand  and  syphilis  and  carcinoma  on  the  other.  Bardeleben 
and  Kohler  were  reserved  in  their  verdict  as  to  the  diagnostic 
value  of  the  method. 

"  Trendelenberg  regarded  the  febrile  reaction  following  an 
injection  of  tuberculin  as  an  evidence  of  the  tubercular  nature 
of  the  lesion,  except  in  tuberculosis  of  the  testicle.  Esmarch 
was  of  the  opinion  that  in  doubtful  cases  the  reaction  following 
the  use  of  the  remedy  is  of  great  diagnostic  value.  Bramann 
and  Mikulicz  placed  great  confidence  in  the  presence  or  absence 
of  reaction.  Konig  and  Hildebrand  have  observed  reactions 
in  lesions  resembling  in  appearance  tubercular  affections,  but 
which,  by  other  diagnostic  aids,  were  shown  not  to  be  of  a 
tubercular  nature.  Clinical  experience  has  demonstrated  that 
general  reaction  is  produced  by  tuberculin  in  cases  of  actino- 
mycosis  and  in  certain  forms  of  sarcomatous  tumors,  and  that, 
consequently,  this  method  of  diagnosis  cannot  be  relied  upon 
in  differentiating  between  tubercular  lesions  and  these  affections. 

"  A  number  of  cases  reported  in  this  paper  furnish  con- 
clusive proof  that  the  susceptibility  to  general  reaction  varies 
greatly  in  different  tubercular  individuals.  In  some  intense 
reaction  followed  the  use  of  small  doses  when  the  tubercular 
lesion  was  limited  ;  in  others  suffering  from  extensive  tubercu- 
losis large  doses  produced  no  rise  in  temperature.  That  in  the 
latter  class  of  cases  the  affection  was  of  a  tubercular  nature 
there  could  be  no  doubt  from  the  history  of  the  cases,  the 


234  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

appearance  and  location  of  lesions^  and  the  subsequent  behavior 
of  the  affection ;  and  in  some  of  the  cases  the  presence  of 
tubercle  bacilli  in  the  affected  tissue  was  demonstrated. 

"  I  look  upon  the  local  reaction  in  affections  of  the  lymphatic 
glands  as  a  valuable  diagnostic  aid  in  differentiating,  by  the  use  of 
Koch's  lymph,  between  tubercular  and  non-tubercular  affections 
of  these  organs.  If  the  enlargement  of  the  lymphatic  glands 
is  due  to  a  tubercular  affection,  the  existing  swellings  not  only 
become  larger,  more  painful  and  tender  a  few  hours  after  the 
injection  of  a  dose  of  the  lymph,  but  other  glands  that  could 
not  be  felt  before  the  injection  become  enlarged,  and  can  be  felt 
in  the  vicinity  of  those  that  were  recognized  before  the  use  of 
the  remedy.  But  even  in  such  cases  I  regard  inoculation  ex- 
periments of  greater  diagnostic  value  than  injections  of  tuber- 
culin, yielding  more  positive  results  without  exposing  the  patient 
to  the  risks  of  local  and  metastatic  dissemination  of  the  disease 
incident  to  the  latter  procedure. 

"  If  patients  suffering  from  non-tubercular  affectioiVs  will 
occasionally,  only,  respond  to  the  tuberculin  test  on  the  one 
hand,  and  on  the  other,  in  exceptional  cases,  individuals  suffer- 
ing from  well-marked  typical  tubercular  affections  have  proved 
themselves  refractory  to  the  action  of  the  tuberculin,  it  must 
appear  evident  that  the  use  of  this  substance  cannot  be  relied 
upon  in  making  a  positive  differential  diagnosis  between  tuber- 
cular and  non-tubercular  affections.  If  it  can  be  shown,  at  the 
same  time,  that  a  single  injection  of  tuberculin  is  not  devoid  of 
danger,  and  that  implantation  of  the  product  of  this  disease  in 
guinea-pigs  in  the  course  of  three  or  four  weeks  will  yield  re- 
sults which  will  enable  us  to  make  a  reliable  diagnosis  between 
tubercular  and  non-tubercular  affections,  it  is  apparent  that  the 
use  of  Koch's  lymph  as  a  diagnostic  resource  should  be  dis- 
carded, or,  at  least,  limited  to  exceptional  cases. 

"  Therapeutic  Value  of  Tuberculin. — It  is  now  generally 
conceded  that  many  cases  of  tuberculosis  reported  as  cured  have 
since  relapsed ;  some  of  these  have  died,  and  others  have  been 


TUBERCULIN  TREATMENT.  235 

subjected  to  different  treatment.  In  many  instances,  of  course, 
the  original  report  lias  not  been  supplemented  by  subsequent 
communication  ;  as  an  absolute  diagnosis,  even  by  the  use  of 
Koch's  lymph,  is  not  always  possible.  It  may  be  some  of  the 
alleged  cures  rest  on  a  faulty  diagnosis.  This  applies  with 
special  force  to  the  two  cases  of  pulmonary  disease  reported  as 
cured  in  this  paper. 

"  Again,  it  must  not  be  forgotten  that  tubercular  affections 
not  infrequently,  under  favorable  local  or  general  conditions  or 
improved  dietetic,  hygienic  or  climatic  changes,  undergo  a  spon- 
taneous cure;  so  that  for  nearly  all  methods  of  treatment,  so  far 
suggested,  similar  exceptional  results  can  be  claimed.  In  not  a 
single  instance  of  the  eleven  cases  of  surgical  tuberculosis  that 
came  under  my  own  observation  did  the  treatment  result  in  any- 
thing more  than  a  temporary  improvement,  and  in  several  of 
them  it  was  followed  by  local  extension  of  the  disease  and 
serious  impairment  of  the  general  health.  The  effect  of  tuber- 
culin proved  more  serious  in  the  treatment  of  the  forty-three 
cases  of  pulmonary  tuberculosis.  There  can  be  but  little  doubt 
that  in  a  number  of  the  fatal  cases,  death  was  hastened  by  the 
treatment,  and  that  in  a  number  of  the  mild  cases  it  contributed 
largely  toward  the  rapid  local  extension  of  the  lesion  ;  while  the 
tuberculin  treatment  of  pulmonary  tuberculosis  can  show  no 
better  results,  it  is  difficult  to  ignore  the  fact  that  it  has  been 
productive  of  more  harm  than  almost  any  other  plan  of  treat- 
ment heretofore  suggested,  and  on  this  score  alone  the  verdict 
'  Away  with  Koch's  Lymph  ! '  is  timely  and  imperative. 

"  Dangers  Attending  the  Use  of  Tuberculin. — Tuberculin, 
when  brought  in  contact  with  tubercular  tissue,  produces  coagu- 
lation necrosis,  and  during  this  process  a  toxic  chemical  sub- 
stance is  produced,  which,  when  it  reaches  the  general  circula- 
tion, causes  the  febrile  reaction.  The  time  necessary  to  reach 
this  stage  of  its  action  is  usually  from  three  to  six  hours.  The 
intensity  of  the  reaction  depends  on  the  quantity  of  the  toxic 
substance  that  is  produced  and  finds  its  way  into  the  general 


236  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

circulation.  The  general  reaction  is  a  septic  condition  of  the 
organism  produced  by  the  toxic  substance  resulting  from  the 
action  of  the  tuberculin  on  the  tubercular  tissue.  The  temper- 
ature and  the  other  general  symptoms  continue  until  this  toxic 
substance  is  eliminated  through  one  or  more  of  the  excretory 
organs.  The  immediate  danger  attending  the  tuberculin  treat- 
ment consists  in  the  production  and  introduction  into  the  circu- 
lation of  a  fatal  dose  of  this  toxic  substance.  That  the  fear 
of  a  fatal  sepsis  resulting  from  the  action  of  Koch's  lymph  is 
not  unfounded  is  shown  by  a  number  of  such  cases  that  have 
been  reported.  If  the  whole  truth  were  known,  this  number 
would  be  greatly  increased  by  unpublished  cases. 

"  The  more  remote  dangers  attending  the  tuberculin  treat- 
ment have  been  pointed  out  by  Virchow.  The  destructive 
effect  of  the  tuberculin  on  the  granulation  tissue  breaks  down 
the  wall  surrounding  the  infected  area  and  liberates  the  bacilli 
and  their  spores, — an  occurrence  which  can  hardly  fail  in  giving 
rise  to  local  and  general  dissemination.  The  granulation  tissue, 
the  specific  primary  product  of  tubercular  inflammation,  is  the 
wall  of  defense  built  up  by  the  tissues  to  protect  the  adjacent 
parts  and  the  organism  against  invasion.  Any  method  of  treat- 
ment which  interferes  with  this  manner  of  defense  clears  the 
way  for  the  enemy  and  secures  victory  for  the  invading  army. 
If  future  research  should  lead  to  the  discovery  of  a  specific 
remedy  for  the  cure  of  tuberculosis,  it  will  be  an  antagonistic 
microbe  to  the  bacillus  of  tuberculosis,  or  a  substance  which, 
when  brought  in  contact  with  a  tubercular  focus,  will  have  an 
opposite  effect  on  the  tissues  from  that  of  Koch's  lymph. 

"  I  have  given  Koch's  lymph  a  fair  trial  and  have  carefully 
observed  its  effects,  and  have  become  firmly  convinced  both  of 
the  danger  which  attends  its  use  and  its  utter  inutility  in  curing 
any  form  of  tuberculosis." 

This  chapter  has  been  written  for  the  special  purpose  of 
placing  myself  on  record  as  one  who  protests  earnestly  against 
further  experimentation  with  this  mysterious  and  dangerous 


TUBERCULIN  TREATMENT.  237 

fluid.  A  careful  study  of  the  voluminous  literature  on  the  use 
of  Koch's  lymph  and  my  own  experience  with  it  have  induced 
me  to  abandon  the  use  of  Koch's  lymph  both  as  a  diagnostic 
and  therapeutic  agent. 

Professor  Klebs,  of  Zurich,  has  recently  brought  to  the 
attention  of  the  profession  a  purified  preparation  of  Koch's 
lymph,  which  he  calls  tuberculocidin.  In  a  letter  which  the 
author  recently  received  from  him  he  claims  that  the  toxic 
substances  which  made  Koch's  lymph  so  dangerous  have  been 
eliminated,  while  the  therapeutic  value  has  not  been  diminished 
by  the  chemical  processes  to  which  the  crude  lymph  was  sub- 
jected. He  is  enthusiastic  in  his  expectations  of  the  curative 
power  of  this  new  preparation,  but  I  am  free  to  confess  that  I  am 
not  inclined  to  give  this  or  any  other  specific  remedy  for  tuber- 
culosis further  trial  until  -their  therapeutic  value  has  been  fully 
established  by  experimental  research. 


CHAPTER  XXIII. 

TREATMENT  OF   TUBERCULOSIS  OF   JOINTS   BY  PARENCHTMATOUS 
AND  INTRA-ARTICULAR  INJECTIONS. 

THE  successful  treatment,  in  some  cases  of  bone  and  joint 
tuberculosis,  by  parenchymatous  and  intra-articular  injections  is 
one  of  the  important  achievements  of  modern  surgery.  Attempts 
in  this  direction  were  made  long  before  the  bacillus  of  tubercu- 
losis was  discovered,  and  before  the  true  pathology  of  tubercular 
inflammation -was  understood.  It  is,  however,  since  the  true 
nature  of  the  tubercular  process  has  been  revealed,  and  since  the 
antibacterial  action  of  a  number  of  antiseptic  substances  has 
been  carefully  studied  experimentally  and  clinically,  that  this 
method  of  treatment  has  been  placed  upon  a  scientific  basis  and 
has  yielded  satisfactory  results.  It  is  reasonable  to  assume  that 
if,  by  a  harmless  procedure,  safe  and  efficient  chemical  sub- 
stances can  be  brought  in  contact  with  the  affected  tissues  with- 
in diseased  bones  and  joints  that  exercise  a  direct  curative  effect, 
it  would  constitute  a  decided  improvement  over  former  methods 
of  treatment  by  internal  administration  or  external  application 
of  the  same  remedies.  The  remedies  which  have  been  used  for 
this  purpose  possess  potent  antiseptic  and  stimulating  properties, 
and  have  been  employed  with  a  view  to  destroy  the  microbic 
cause  of  the  disease,  and  to  aid  and  expedite  the  process  of 
repair. 

The  first  attempts  at  intra-articular  medication  were  made 
with  a  Pravaz  syringe,  the  solution  being  thrown  into  the  joint 
without  previous  evacuation  of  its  fluid  contents.  At  the  present 
time  the  joint  is  punctured  with  a  larger  instrument,  and  if  it 
contain  fluid  this  is  evacuated  before  the  injection  is  made.  If 
the  joint  contain  tubercular  pus,  the  intra-articular  injection  is 
preceded  by  irrigation  of  the  joint  with  a  mild  antiseptic  solu- 
tion. The  best  instrument  for  puncturing  a  joint  is  a  small 
trocar,  through  the  cannula  of  which  the  joint  can  be  emptied, 
(238) 


PARENCHYMATOUS   AND   INTRA-ARTICULAR   INJECTIONS.        239 

irrigated,  and  injected.  The  puncture  is  to  be  made  under 
strictest  antiseptic  precautions,  and  in  accordance  with  the  rules 
laid  down  elsewhere.  In  tubercular  empyema  of  a  joint,  irriga- 
tion should  never  be  neglected  as  a  preliminary  step  to  the  intra- 
articular  injection.  The  simplest  method  of  irrigating  a  joint  is 
to  connect  the  cannula  with  a  rubber  tube  attached  to  an  irrigator 
holding  the  antiseptic  solution.  A  2-per-cent.  solution  of  boric 
acid  or  a  one-third  of  1-per-cent.  solution  of  salicylic  acid  in 
sterilized  water  should  be  used  for  this  purpose.  The  connec- 
tion between  cannula  and  rubber  tube  should  only  be  made  after 
the  surgeon  has  been  satisfied  that  neither  of  them  contains  at- 
mospheric air.  By  elevating  the  irrigator  the  fluid  enters  the 
joint,  and  the  infusion  should  be  continued  until  the  capsule  is 
thoroughly  distended,  when  the  rubber  tube  is  detached  and 
the  fluid  evacuated  through  the  cannula  by  compressing  the 
joint.  This  procedure  is  repeated  until  the  fluid  returns  per- 
fectly clear.  The  intra-articular  injection  is  made  with  an  ordi- 
nary one-ounce  glass  syringe,  to  the  nozzle  of  which  a  piece  of 
aseptic  rubber  tubing  is  attached,  which  is  fastened  to  the  end 
of  the  cannula  with  the  same  care  as  in  making  the  irrigation. 
The  quantity  of  fluid  which  is  to  be  injected  should  never  be 
large  enough  to  cause  painful  distension.  After  the  cannula  is 
withdrawn  the  puncture  should  be  sealed  with  a  pledget  of 
aseptic  cotton  and  collodium. 

Among  the  many  substances  which  have  been  used  for 
parenchyma  tons  and  intra-articular  medication,  I  will  only  make 
mention  of  such  that  have  received  the  most  attention,  and  which 
experience  has  shown  to  be  of  some  value. 

Tincture  of  Iodine. — This  preparation  of  iodine,  pure  or 
diluted  with  a  solution  of  potassic  iodide,  was  one  of  the  first 
substances  employed  for  intra-articular  medication.  The  late 
Professor  Brainard,  of  Chicago,  made  extensive  use  of  it  in  the 
treatment  of  chronic  hy drops  of  joints.  Usually  the  injection 
was  made  through  the  cannula  of  a  trocar  after  the  joint  had 
been  emptied  of  its  contents.  The  violent  local  and  general 


240  TUBERCULOSIS    OF    THE   BONES    AND   JOINTS. 

reaction  which  sometimes  followed  the  injection  was  in  the  way 
of  a  more  general  adoption  of  this  method  of  treating  diseased 
joints.  It  has  yielded  satisfactory  results  in  the  treatment  of 
catarrhal  synovitis,  as  the  vasomotor  irritation  which  the  iodine 
produces  upon  the  inner  surface  of  the  cavity  of  the  joint  and 
the  vascular  changes  connected  with  it  hring  about  speedy 
retrograde  metamorphosis  of  the  inflammatory  product  and 
hasten  the  process  of  absorption.  It  is  never  safe,  even  in  such 
cases,  to  allow  the  tincture  to  remain  in  the  joint,  as  the  desired 
therapeutic  effect  can  be  obtained  by  injecting  through  the 
cannula  of  the  trocar  from  2  to  4  drachms  of  the  tincture,  and, 
after  bringing  it  in  contact  with  the  entire  surface  of  the  joint 
by  flexion  and  extension,  friction  and  compression  allow  it  to 
escape. 

In  the  treatment  of  tubercular  joints  this  remedy  has  not 
only  proved  a  failure,  but  has  often  been  followed  by  aggrava- 
tion of  the  local  conditions,  and  should  be  stricken  from  the  list 
of  therapeutic  resources  in  the  treatment  of  these  affections. 

Carbolic  Acid. — Soon  after  carbolic  acid  was  introduced 
into  surgical  practice  as  an  antiseptic  agent,  it  was  also  employed 
in  the  treatment  of  chronic  inflammation  of  joints  as  an  intra- 
articular  injection.  Hueter*  resorted  to  parenchymatous  and 
intra-articular  injections  of  a  2-  to  3-per-cent.  solution  of  car- 
bolic acid  in  the  treatment  of  chronic  inflammation  of  bones  and 
joints,  upon  the  supposition  that  the  carbolic  acid,  when  brought 
in  direct  contact  with  the  diseased  tissues,  would  destroy  the 
microbic  cause  of  the  inflammation.  The  injections  were  made 
with  a  Pravaz  syringe  every  other  day.  In  a  case  of  osteomye- 
litis granulosa  hyperplastica,  the  favorable  effect  of  the  injec- 
tions became  apparent  soon  after  the  treatment  was  commenced. 
Twenty  injections,  in  the  course  of  five  weeks,  resulted  in  a 
permanent  cure. 

Hueter's  treatment  was  quite  generally  adopted  in  Germany, 

*  "Die  "Wirkungen  der  parenchymatosen  Carbolinjectioneu  bei  Entziideugen  der  Gelenke 
und  Knochen."    Deutsche  Zeitschrift  f.  Chirurgie,  B.  iv,  p.  526 ;  B.  v,  p.  120. 


PARENCHYMATOUS    AND    INTRA-ARTICULAR    INJECTIONS.        '241 

but  the  results,  on  the  whole,  were  so  unsatisfactory  that  it  was 
soon  abandoned.  The  results  have  not  been  more  encouraging 
by  puncture  and  irrigation  of  the  joint  with  solutions  of  carbolic 
acid,  and  at  the  present  time  carbolic  acid  has  been  given  up 
almost  completely  as  an  antitubercular  remedy.  The  same  fate 
has  met  the  folio  winy  two  substances: — 

O 

Arsenious  Acid. — Cavagnis,*  of  Venice,  made  a  number 
of  experiments  on  rabbits  and  guinea-pigs  to  determine  the 
therapeutic  value  of  arsenic  in  the  treatment  of  tuberculosis. 

On  April  17,  1881,  four  rabbits,  two  gray  and  two  black, 
weighing,  respectively,  1580,  1590,  1660,  and  1680  grammes, 
and  four  guinea-pigs,  weighing  370,  500,  510,  and  610  grammes, 
were  inoculated  with  tubercular  material  by  subcutaneous  injec- 
tion. From  the  date  of  inoculation  until  May  28th,  the  gray 
rabbits  received  1  drop  of  Fowler's  solution,  diluted  with  distilled 
water,  daily;  the  medicine  was  injected  into  the  back  part  of 
the  mouth  with  a  Pravaz  syringe;  the  black  rabbits  were  given 
2  drops  daily  in  the  same  manner,  while  the  guinea-pigs  received 
only  half  a  drop.  The  smallest  guinea-pig  was  killed  May  21st, 
all  the  other  animals  June  6th.  One  of  the  rabbits  and  all  of 
the  guinea-pigs  were  tubercular.  A  tubercular  ulcer  at  the 
point  of  inoculation  had  developed,  the  tissues  of  which  con- 
tained numerous  bacilli;  cheesy  foci  in  the  vicinity  of  the  ulcer; 
lumbar  and  prehepatic  glands  enlarged  and  partly  cheesy ; 
spleen  enlarged,  containing  numerous  tubercles;  liver  also  the 
seat  of  tuberculosis.  One  of  the  guinea-pigs  had  nine  small 
tubercles  in  the  lungs. 

.The  other  three  rabbits  presented  an  encapsulated  abscess 
at  site  of  inoculation,  and  one  or  two  small,  cheesy  masses  in  the 
vicinity,  but  aside  from  this  Jio  evidence  of  tuberculosis  could  be 
detected.  Inoculations  made  with  the  contents  of  the  abscesses 
yielded  negative  results. 

Landerer  used  this  substance  dissolved  in  distilled  water  in 
the  proportion  of  1  to  1000,  and  of  this  he  injected  from  one  to 

*  Etudes  de  la  Tuberculose,  p.  462. 
16 


242  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

two  syringefuls  at  intervals  of  a  few  days  into  the  affected  joint. 
The  results  must  have  been  decidedly  unfavorable,  as  it  does 
not  appear  that  this  remedy  was  used  for  the  same  purpose  by 
others. 

Corrosive  Sublimate. — Next  to  carbolic  acid  corrosive  sub- 
limate has  been  used  more  extensively  as  an  antiseptic  in  the 
treatment  of  wounds  than  any  other  substance,  but  has  never 
been  popular  as  an  antitubercnlar  remedy.  Experiments  made 
by  Cavagnis*  to  test  its  antibacillary  action  yielded  very  favor- 
able results  as  far  as  its  action  is  concerned  in  preventing  the 
growth  of  tubercle  bacilli  in  the  tissues  of  the  rabbits. 

On  April  17.  1887,  he  inoculated  three  rabbits  and  three 
guinea-pigs  with  tubercular  material,  and  subjected  these  ani- 
mals at  once  to  a  thorough  treatment  with  corrosive  sublimate, 
which  was  administered  in  doses  of  4  drops  of  a  solution  of  1 
to  100  of  distilled  water,  while  the  guinea-pigs  received  only 
one-fourth  of  this  quantity.  May  1st,  one  rabbit  died;  another 
May  10th;  the  animals  were  very  much  emaciated,  and  the 
necropsy  revealed  a  small  mass  of  cheesy  appearance  at  the 
point  of  injection ;  no  bacilli  could  be  found  in  the  caseous  ma- 
terial, and  the  internal  organs  showed  no  trace  of  tuberculosis. 
The  third  rabbit  became  so  emaciated  that  treatment  was  sus- 
pended May  10th,  and  ten  days  later  the  animal  died.  A  large 
abscess  containing  non-tubercular  pus  was  found  where  the 
injection  was  made.  Internal  organs  and  lymphatic  glands 
healthy.  The  guinea-pigs  were  killed  June  7th.  These  ani- 
mals presented  a  tubercular  ulcer  at  the  site  of  injection ;  exten- 
sive tuberculosis  of  the  lymphatic  glands,  spleen,  and  liver. 

Vogt  injected  from  three  to  five  syringefuls  of  the  following 
solution  into  tubercular  joints:  Corrosive  sublimate,  0.1  ;  sodic 
chloride,  1.0;  distilled  water,  50.0.  Evidently  without  success, 
as  Vogt  himself  soon  suspended  its  use. 

Another  remedy  that  seems  to  have  been  used  only  by  the 
one  who  suggested  it  and  a  few  others  is 

*  Op.  cit. 


PARENCHTMATOUS    AND    INTRA-ARTICULAR   INJECTIONS.       243 

Phosphate  of  Lime. — Kolisclier*  used  an  acidulated  solu- 
tion of  phosphate  of  lime  for  parenchymatous  and  intra-articular 
injections  in  tuberculosis  of  bones  and  joints.  The  injections 
were  made  with  an  ordinary  Pravaz  syringe.  Pain  and  other 
symptoms  of  local  reaction  always  followed  the  injection  and 
continued  for  five  to  six  days,  after  which  the  limb  was  immo- 
bilized. After  this  the  swelling  diminished  in  size  and  the 
tissues  became  firmer,  showing  that  healing  by  cicatrization 
was  progressing  in  a  satisfactory  manner. 

E.  Freundf  gives  full  directions  for  the  preparation  of  the 
solution  and  gauze  of  acid  phosphate  of  lime. 

In  another  publication  Kolischer^:  reports  five  hundred 
cases  treated  by  his  method,  and  admits  that,  while  tubercular 
joint  affections  were  benefited  by  the  treatment,  it  had  no  such 
influence  in  cases  of  central  foci  in  bone  and  the  sequestrating 
form  of  bone  tuberculosis.  This  treatment  was  faithfully  tried 
in  the  Klinik  at  Tubingen,  but  with  negative  results,  as  we 
learn  from  the  paper  published  by  E.  Miiller.  §  It  is  not  prob- 
able that  the  use  of  this  remedy  will  be  revived  in  the  future  in 
the  treatment  of  tubercular  affections  of  bones  and  joints. 

Chloride  of  Zinc. — Lannelongue  made  an  important  con- 
tribution to  the  Academy  of  Medicine  of  Paris,  concerning  the 
local  treatment  of  tuberculosis  by  injections  of  solutions  of 
chloride  of  zinc.  His  attention  was  called  to  this  remedy 
during  the  treatment  of  a  case  of  lymphangioma.  He  noticed 
that  one  of  its  effects  was  its  power  of  changing  softened  tissues 
into  hard  fibrous  structures.  During  the  last  few  months  he 
treated  twenty  cases  of  surgical  tuberculosis  by  parenchymatous 
injections  of  a  solution  of  chloride  of  zinc.  The  injection  is 
made  into  the  periphery  of  the  tubercular  lesions,  so  as  to  stim- 

*  "  Bin  neues  Heilverfahren  bei  lokalisirten  Tuberculosen  Processen."  Wiener  Med. 
Presse,  B.  xxviii,  No  22,  1887. 

t  "Ueber  die  bei  Kalkbehandlung  der  localtuberculose  zur  Verwendung  gelangender 
Losungen."  Wiener  Med.  Presse,  B.  xxviii.  No.  24,  1887. 

J  "Erfahrungen  iiber  die  Kalkbehandlung  bei  Localtuberkulose."  Wiener  Med.  Presse, 
B.  xxvii,  No.  29. 

§  "Ueber  die  Kalkbehandlung  der  localisirten  tuberculosen  Processe."  Centralblatt  f. 
Chirurgie,  No.  15, 1888. 


244  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

ulate  the  surrounding  healthy  tissue  to  active  proliferation,  by 
which  the  focus  is  encapsulated.  For  tubercular  disease  of  the 
knee  four  or  five  injections  are  usually  made  around  the  circum- 
ference of  the  superior  cul-de-sac.  From  8  to  10  drops  of  the 
solution  (10  per  cent.)  suffice  for  the  knee  of  a  child  aged  10. 
He  claims  excellent  results  in  the  treatment  of  tuberculosis  of 
the  lymphatic  glands,  and  reports  a  few  joint  cases  similarly 
benefited. 

Balsam  of  Peru. — More  than  thirty  years  ago,  Sayre  em- 
ployed balsam  of  Peru  in  dressing  wounds  after  resection  of 
joints  for  tubercular  affections.  The  results  following  his 
operations  were  much  better  than  the  average  in  the  hands  of 
other  surgeons  at  that  time,  and  we  must  attribute  them,  at 
least  in  part,  to  the  use  of  this  substance  as  a  wound-dressing. 

Quite  recently  Landerer*  has  again  called  attention  to  the 
utility  of  the  action  of  this  antiseptic  in  arresting  tubercular 
inflammation.  As  the  result  of  his  experiments  on  animals  and 
from  clinical  experience  with  this  remedy,  he  has  come  to  the 
conclusion  that  its  therapeutic  action  is  owing  to  its  stimulating 
effect  on  the  tissues,  which  brings  the  parts  in  such  a  condition 
as  to  render  the  pathogenic  action  of  tubercle  bacilli  harmless. 
He  ascertained,  by  his  experiments  on  rabbits  that  had  been  ren- 
dered tubercular  by  inoculation,  that  the  disease  was  favorably 
influenced  by  innocuous  injections  of  an  alkaline  emulsion  of  this 
drug.  In  the  treatment  of  fistulse  and  deep-seated  tubercular 
processes  he  uses  a  solution  of  the  balsam  in  sulphuric  ether  1 
to  5  for  injection. 

For  parenchymatous  injections  he  employs  an  emulsion  of 
the  strength  of  1  to  4  composed  of  oil  of  sweet  almonds  and  a 
.07-per-cent.  solution  of  sodic  chloride. 

He  reports  twenty-five  cases  of  tuberculosis  of  bone,  gen- 
erally implicating  joints,  greatly  improved  by  injections  of  an 
emulsion  of  balsam  of  Peru  combined  in  some  cases  witli  minor 

*  "Eine  neue  Behandlungsweise  tuberculoser  Processe."    Munch.  Med.  Wochenschrift, 
No.  40,  1888. 


PARENCHYMATOUS   AND   INTRA-ARTICULAR   INJECTIONS.       245 

operative  procedures,  and  in  some  of  these  cases  the  joint  affec- 
tions were  so  serious  that  amputation  was  proposed,  but  the 
operation  was  refused  by  the  patients. 

Vamossy*  has  made  extensive  use  of  gauze  prepared  with 
balsam  of  Peru  in  the  treatment  of  open  wounds  after  the  re- 
moval of  tubercular  products  with  signal  success.  He  reports 
twenty-eight  cases  treated  according  to  Lan-derer's  method,  and 
expresses  himself  as  satisfied  with  the  results.  Among  these 
cases  he  observed  albuminuria  three  times,  cystitis  twice,  and 
acute  nephritis  once,  —  affections  of  the  genito-urinary  organs 
which  he  believes  were  cured  by  the  balsam. 

Binzf  also  calls  attention  to  the  irritating  effect  of  this  drug 
on  the  urinary  apparatus. 

Landerer  thinks  the  danger  in  the  use  of  the  balsam  has 
been  greatly  overestimated,  and  that  it  can  be  avoided  by  proper 
care  in  its  use.  Although  balsam  of  Peru  does  not  appear  to  pos- 
sess any  direct  antibacillary  properties,  there  can  be  no  doubt  that 
it  can  be  applied  with  great  benefit  in  the  treatment  of  tubercu- 
losis of  bones  and  joints,  especially  after  fistulous  openings  and 
open  ulcerating  surfaces  have  formed,  as  well  as  a  dressing  after 
resection  of  joints  and  the  treatment  of  tubercular  abscesses  by 
incision  and  curetting. 

Camphorated  Naphthol.  —  Camphorated  naphthol  was  first 
prepared  by  Desesquelle,  in  1888,  and  was  first  used  in  the  sur- 
gical service  of  Percer,  at  the  Hopital  Lariboisiere.  It  is  a 
liquid  prepared  by  taking  /3-naphthol  100  grammes,  camphor 
200  grammes,  pulverizing  each  substance  finely,  gently  heating 
the  mixture  until  complete  fusion  ;  filter  and  preserve  the 
liquid  obtained  in  yellow-glass  bottles,  well  corked.  It  possesses 
valuable  antiseptic  properties,  and  is  strongly  recommended  by 
^:  in  the  treatment  of  tuberculosis  of  bones  and  joints. 


*"Zur  Therapie  der  Localtuberculose  mit  Perubalsam."  Wiener  Med.  Presse,  B.  xxx, 
Nos.  17-20,  1889. 

t  "  Ueber  den  Perubalsam."    Centralblatt  f.  klin.  Medicin.,  B.  x,  1889. 

\  "Contribution  a  1'etude  du  Traitement  de  la  tuberculose  des  os,  des  articulations  et  des 
Synovialis  tendineuses  de  1'emploi  du  Naphtbol  Camphre."  Etudes  experimeutales  et  cliniques 
sur  la  Tuberculose,  Paris,  1888-90,  p.  608. 


246  .TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

He  believes  that  in  the  local  treatment  of  these  affections  the 
employment  of  potent  antiseptic  remedies  is  indicated,  and  such 
substances  should  be  selected  which,  of  equal  therapeutic  value, 
are  non-toxic,  so  that  they  can  be  used  freely  and  for  a  long 
time.  According  to  his  estimation  camphorated  naphthol  fills 
these  two  conditions,  being  only  slightly  toxic,  an  efficient  anti- 
septic, and  destructive  to  the  tubercle  bacillus.  As  naphthol 
camphor  dissolves  iodine,  the  following  mixture  can  be  used: — 

Naphthol  camphor,          .  90.0 

Iodine, 10.0 

The  antiseptic  properties  of  camphor  naphthol  have  been 
demonstrated  experimentally  \yy  Maximowitch,  Park,  Burrel, 
and  Edington,  and  corroborated  by  the  clinical  results  of  Nicaise, 
Fernet,  Schwartz,  Peyrot,  Reboul,  and  others.  The  successful 
treatment  of  local  tubercular  foci  by  camphor  naphthol  has 
been  established  by  the  results  obtained ;  but  the  action  of  this 
drug  seems  to  be  general  as  w  ell,  since  the  naphthol  is  absorbed 
and  has  been  found,  in  a  free  state,  in  the  urine  of  persons 
dressed  with  camphorated  naphthol  (Uesesquelle). 

If  a  wound,  after  operations  for  tubercular  affections,  is 
dressed  with  camphorated  naphthol  the  urine  shows  the  presence 
of  naphthol  for  eight  days,  showing  that  its  local  and  general 
action  is  prolonged,  and  may  prevent  relapses,  secondary  inocu- 
lations,— complications  following  so  frequently  operations  for 
local  tuberculosis. 

Perier  and  Reboul  have  employed  camphorated  naphthol 
extensively  as  an  injection,  in  doses  varying  from  50  to  100 
grammes,  in  the  treatment  of  articular  tuberculosis  and  tuber- 
cular abscesses,  with  favorable  results.  The  injections  did  not 
produce  pain,  and  were  never  followed  by  violent  local  reaction 
or  symptoms  of  intoxication. 

Parenchymatous  injections  made  with  an  ordinary  Pravaz 
syringe  proved  equally  successful  in  the  different  forms  of  local 
tuberculosis.  The  injections  were  repeated  every  eight  days. 

Reboul  reports  a  large  number  of  cases  of  tuberculosis  of 


PARENCIIYMATOUS    AND    INTRA-ARTICULAR   INJECTIONS.       247 

bones  and  joints  treated  by  incision,  scraping  and  injections,  and 
dressings  of  naphthol  camphor,  in  which  the  results  were  all 
that  could  be  desired, — speedy  healing  of  the  wounds  and  free- 
dom from  relapse.  In  a  number  of  cases  of  spina  ventosa,  punc- 
ture and  parenchymatous  injections  of  camphor  naphthol,  re- 
peated weekly,  resulted  in  a  permanent  cure  within  three 
months.  He  believes  that  the  curative  effect  of  camphor 
naphthol,  like  other  antitubercular  remedies,  when  applied 
locally,  consists  mainly  in  the  production  of  an  irritative  ostitis, 
and  supports  this  opinion  by  citing  the  case  of  a  patient  treated 
for  a  tubercular  lesion  of  the  great  trochanter  with  camphor- 
ated naphthol,  who  died  of  pulmonary  tuberculosis.  Around 
the  tubercular  focus  which  had  been  treated  the  bone  presented 
the  characteristic  appearances  of  plastic  osteomyelitis,  and  no 
bacilli  or  miliary  tubercles  could  be  found.  The  action  of  the 
remedy  substitutes  for  the  tubercular  a  plastic  osteomyelitis. 

Reboul  has  great  faith  in  the  conscientious  use  of  camphor 
naphthol  as  a  local  application  and  dressing,  in  resection  of 
tubercular  joints,  in  securing  an  aseptic  healing  of  the  wound 
and  guarding  against  local  relapses  and  general  miliary  tuber- 
culosis. He  cites  a  number  of  operations  of  this  kind  on  the 
larger  joints  in  which  this  remedy  was  relied  upon  exclusively 
as  an  antiseptic,  and  the  results  certainly  appear  to  corroborate 
the  claims  made  for  it. 

He  has  also  been  satisfied  with  the  results  of  interstitial 
injections  with  camphor  naphthol  in  the  treatment  of  fungous 
disease  of  joints. 

lodoform. — Injections  of  iodoform  in  the  treatment  of  tuber- 
culosis of  bones  and  joints  and  tubercular  abscesses  were  ad- 
vised by  Billroth  and  Mikulicz*  ten  years  ago,  and  the  latter 
published  another  paper  on  this  subject  a  year  later  ;f  but  it  was 
not  until  a  few  years  later  that  it  came  into  more  general  use, 
through  the  teachings  and  writings  of  Mosetig  von  Moorhof4 

*  Berliner  klin.  Woehenschrift,  1881. 

f'Die  Verwendung  des  lodofonns  in  der  Chirurgie."     Archiv  f.  klinische  Chirurgie, 
B.  xvii,  p.  3,  1882. 

| "  Zur  lodoformfrage."    Weiner  Medicinische  Blatter,  B.  viii,  Nos.  10-12,  1885. 


248  TUBERCULOSIS   OF    THE   BONES    AND    JOINTS. 

Mazzoni*  believes  that  iodol-ether-glyccrin  injections  into 
the  tissues  or  joints  has  a  favorable  effect  on  tubercular  lesions 
not  only  in  arresting  the  disease,  but  also  in  expediting  the 
subsequent  reparative  process. 

At  the  present  time  the  antitubercular  action  of  iodoform 
is  generally  recognized  from  a  clinical  stand-point,  but  the  re- 
sults obtained  by  different  experimenters  on  the  lower  animals 
concerning  the  same  questions  are  at  variance. 

Experimental  Studies. — Troje  and  Tangl,f  to  test  the  anti- 
bacillary  action  of  iodoform,  devised  the  following  series  of  ex- 
periments :  Iodoform  vapor  and  powder  were  allowed  to  act  on 
pure  cultures ;  the  powder  was  dusted  on  the  culture  medium 
in  the  neighborhood  of  cultures,  and  the  vapor  was  allowed  to 
accumulate  in  the  culture  chamber ;  animals  were  then  inocu- 
lated with  the  growth  and  a  series  of  "  controls  "  was  made. 
The  vapor  killed  the  bacilli  only  after  fifty  days,  but  then  sup- 
puration was  produced  by  the  action  of  chemical  products,  as 
pointed  out  by  Koch.  After  the  vapor  had  acted  six  days, 
however,  the  rapidity  of  the  growth  of  the  bacillus  was  dimin- 
ished, whilst  it  had  quite  ceased  at  the  end  of  four  weeks,  and 
the  bacilli  at  this  stage  were  distinctly  weakened.  When 
strewed  on  the  culture  the  drug  so  diminished  the  virulence  of 
the  bacillus  that  after  sixteen  days  nothing  but  cold  abscesses 
were  formed  after  inoculation,  many  giant-cells  being  present, 
and  the  course  of  the  disease  was  very  chronic.  When  mixed 
in  the  proportion  of  one  part  of  the  active  culture  to  fifteen 
parts  of  iodoform,  it  was  found  that  the  bacilli  were  not  always 
killed  in  fourteen  days,  although  in  one  case  they  were  quite 
innocuous  at  the  end  of  eight  days  ;  at  the  end  of  three  weeks 
they  were  dead,  or  at  any  rate  harmless.  The  authors  found 
also  that  they  could  obtain  bacilli  which  would  set  up  only 
chronic  tubercle  by  means  of  the  action  of  the  iodoform  out- 

*"Ueber  die  Amwendung  des  lodols  in  der  chirurgischen  Praxis."  Berliner  klin.  Woch- 
enscrift,  No.  41,  1886. 

t Berliner  klin.  Wochenschrift,  No.  20,1891.  Supplement  to  British  Med.  Journal,  July 
18,  1891. 


PARENCHYMATOUS    AND    INTRA-ARTICULAR    INJECTIONS.       249 

side  the  body,  for  when  inoculating-  tubercle  bacilli  so  treated 
they  obtained  a  disease  which  was  identical  with  Perlsucht, 
botli  in  its  clinical  and  pathological  characters.  Mixed  with 
olive-oil  or  glycerin,  in  proportions  of  one  part  of  iodoform  to 
ten  of  the  vehicle,  they  found  that  the  organism  was  killed  in 
sixteen  days,  the  oil  and  the  iodoform  being  much  more 
efficacious  than  the  glycerin  mixture.  Virulent  bacilli  can 
grow  in  the  tissues,  whatever  iodoform  mixture  be  intro- 
duced along  with  them,  this  being  due  to  the  fact  that  the  tis- 
sues are  such  a  good  medium  for  the  growth  of  the  organism 
that  the  energy  of  the  latter  becomes  very  great,  and  the 
iodoform  can  exert  little  action  on  its  growth;  although  out- 
side the  body,  where  the  conditions  for  growth  are  not  so 
favorable,  the  iodoform  has  a  decided  inhibitory  effect.  In 
the  case  of  cold  abscesses  the  growth  of  the  bacillus  is  not  so 
active,  and  therefore  the  iodoform  has  a  better  chance  of  ex- 
erting its  valuable  therapeutic  properties.  The  authors  found 
that  the  iodoform  must  act  directly  on  the  bacilli,  as  they  have 
been  able  to  demonstrate  that  it  has  a  deleterious  irritant  action 
on  the  tissues ;  they  also  find  that  the  action  is  most  satisfac- 
tory in  those  cases  where  the  number  of  bacilli  is  compara- 
tively small,  in  which  case  the  iodoform  appears  to  prevent 
the  growth  of  the  bacilli.  Their  investigations  have  led  them 
to  the  practical  conclusion  that  iodoform  is  a  true  disinfecting 
agent  as  far  as  the  tubercle  bacillus  is  concerned;  that  it  has  a 
direct  destructive  effect  upon  the  bacillus  if  left  sufficiently 
long  in  contact.  They  have  also  shown  that  this  drug  dimin- 
ishes the  virulence  of  the  tubercle  bacillus,  and  that  cultures 
thus  treated  produce  a  more  benign  form  of  tuberculosis  in 
animals. 

Gosselin*  made  a  series  of  experiments  on  animals  with 
mercurial  preparations  and  iodoform,  in  order  to  ascertain  if 
any  of  these  substances  could  so  alter  the  tissues  as  to  render 

*  "  Sur  1'attenuation  du  virus  de  la.tuberculose."    Etudes sur  la  tuberculose,  ler  Juillet, 
1887. 


250  TUBERCULOSIS   OP   THE   BONES   AND   JOINTS.  _ 

them  unfit  as  a  soil  for  tho  tubercle  bacillus.  He  reasoned 
that  if  such  a  condition  could  be  brought  about  by  the  intro- 
duction of  chemical  substances  otherwise  harmless,  an  existing 
tubercular  focus  would  be  harmless,  as  local  and  general  dis- 
semination could  no  longer  occur.  Experiments  with  mercuric 
bichloride  and  biniodide  had  no  effect  in  this  direction.  On 
the  other  hand,  these  mercurial  salts  appeared  to  aggravate 
the  tubercular  process.  lodoform  yielded  better  results.  It 
was  administered,  like  the  salts  of  mercury,  subcutaneously.  It 
was  his  intention  to  render  the  animals  refractory  to  the 
tubercle  bacillus  by  saturating  the  tissues  with  iodoform  prior  to 
the  inoculation.  He  used  a  solution  of  iodoform  of  10  to  100. 
Six  rabbits  were  selected,  three  of  which  were  subjected  to 
iodoform  treatment,  while  the  remaining  three  were  not  thus 
treated,  but  kept  under  exactly  similar  conditions.  Three 
drops  of  the  ethereal  solution  of  iodoform  were  injected  under 
the  skin  every  day  for  two  months.  In  the  beginning  the  iodo- 
form was  badly  borne,  as  it  diminished  the  appetite  and  caused 
frequent  attacks  of  diarrhoea,  and  the  animals  cowered  in  a 
corner  of  a  cage  and  showed  no  inclination  to  move  about. 
These  symptoms  always  disappeared  with  the  suspension  of  the 
injections.  After  a  few  days  all  the  secretions  and  the  tissues 
in  different  parts  of  the  body  responded  to  the  iodine  test. 

The  injections  had  to  be  made  with  great  care,  as  they 
were  often  followed  by  acute  inflammation  of  the  skin  and  sub- 
cutaneous cellular  tissue.  Four  months  later  all  of  the  animals 
were  inoculated.  The  three  control  animals  died  of  tuberculosis 
in  from  thirty  to  fifty  days  ;  the  iodoformized  animals  showed  a 
partial  immunity,  and  manifested  no  symptoms  of  tuberculosis 
until  the  expiration  of  fifty  days,  and  death  did  not  occur  until 
from  the  seventieth  to  the  ninetieth  day  after  inoculation. 

The  same  experiments  were  repeated  three  times  with 
identical  results.  In  two  instances  the  iodoformized  animals 
were  killed,  respectively,  on  the  twenty-fifth  and  thirtieth  days 
after  operation. 


PARENCHYMATOUS   AND   INTRA-ART1CULAR    INJECTIONS.       251 

'//,,,, 

Nothing  iurther  was  found  at  the  point  of  inoculation,  than 
a  slight  circumscribed  peritonitis  in  one  and  a  limited  area'  of 
adhesion  between  the  peritoneal  surfaces  in  the  other.  Exami- 
nation of  specimens  stained  by  Ehrlich's  method  showed  numer- 
ous bacilli  in  the  adherent  parts,  and  a  fragment  of  lymph 
deposited  on  the  surface  implanted  into  the  peritoneal  cavity  of 
a  guinea-pig  caused  death  from  tuberculosis  in  twenty-seven 
days.  lodoformized  guinea-pigs  proved  more  refractory  to  the 
tubercle  bacillus  than  rabbits ;  in  one  instance  the  animal  lived 
one  hundred  and  two  days  after  inoculation. 

In  another  very  interesting  series  of  experiments,  Gosselin 
reversed  the  experiments,  rendering  the  animals  first  tubercular 
by  inoculation  and  then  resorting  to  treatment  with  iodoform. 
In  these  experiments  rabbits  and  guinea-pigs  were  used. 

Soon  after  the  animals  were  inoculated  with  tubercular 
matter,  daily  subcutaneous  injections  of  two  to  three  drops  of 
iodoform  ether  (1  to  10)  were  made,  suspending  the  treatment 
as  soon  as  iodoform  intoxication  set  in  and  beginning  anew 
when  it  disappeared,  grading  the  absorption  of  iodoform  so 
as  to  obtain  the  maximum  impregnation  of  the  organism  with 
this  drug  compatible  with  life  in  the  shortest  possible  space 
of  time. 

The  experiments  showed  that  susceptibility  to  iodoform 
differs  not  only  in  the  same  species  of  animals,  but  also  in  dif- 
ferent members  of  the  same  family.  If  the  animal  is  not  closely 
watched  it  will  die  quickly,  poisoned  by  the  combined  action  of 
ether  and  iodoform. 

Three  rabbits  and  two  guinea-pigs  remained  well  ninety- 
five  days  after  inoculation,  and  were  killed,  and  the  most  care- 
ful search  showed  no  trace  of  tuberculosis  at  the  point  of 
inoculation,  and  all  of  the  organs  presented  a  perfectly  healthy 
appearance. 

Two  rabbits  and  one  guinea-pig  were  in  good  health  one 
hundred  and  sixty  days  after  inoculation.  The  two  rabbits  were 
considerably  emaciated  and  their  appetite  somewhat  diminished. 


0«fA-          v  \V>'^ 
•  o  ••  „-*  *  • 

\ *  —  *A    * 

^A:^  w* 


-V  wv 

25^..  ^         TUBERCULOSIS   OF   THE   BONES   AND    JOINTS. 

These  symptoms  were  due  to  the  iodoform,  for  as  soon  as  the 
use  of  this  remedy  was  suspended  the  animals  were  restored  to 
perfect  health.  The  dose  of  iodoform  was  diminished  every 
five  days  for  a  fortnight.  A  third  rabbit  died  from  iodoform 
poisoning  on  the  thirteenth  day,  and  a  careful  autopsy  did  not 
reveal  a  trace  of  tuberculosis.  At  the  seat  of  injection  there 
was  a  circumscribed  inflammatory  exudation,  apparently  free 
from  bacilli.  Two  guinea-pigs  were  inoculated  with  fragments 
of  tissue  from  this  place,  and  these  animals,  with  the  exception 
of  slight  emaciation,  remained  in  good  health  one  hundred  and 
sixty-one  days  later. 

These  studies  appear  to  prove  that  the  prolonged  use  of 
iodoform  by  subcutaneous  injection,  carried  to  the  point  of  toxic 
symptoms,  prevents,  or  at  least  retards,  the  extension  of  the 
tubercular  process. 

Thiery*  does  not  believe  that  iodoform  possesses  such 
direct  antitubercular  properties  as  expressed  by  Gosselin,  but 
he  is  willing  to  admit  that  it  has  a  potent  influence  in  retard- 
ing the  tubercular  process.  In  opposition  to  the  conclusions 
drawn  by  Gosselin,  he  reminds  his  readers  that  it  is  well  known 
that  tuberculosis,  under  favorable  circumstances,  is  occasionally 
spontaneously  cured  or  curable.  In  one  hundred  and  thirty- 
one  autopsies  made  at  the  Morgue  Vibert  he  noticed  evidences 
of  a  former  tubercular  process,  which  had  become  arrested 
spontaneously,  and  the  patients  succumbed  to  other  diseases. 
In  seventeen  out  of  the  twenty-five  cases  the  former  tubercular 
depot  was  indicated  by  a  cicatrix  or  chalky  deposit.  As  further 
proof  that  tuberculosis  does  not  always  manifest  progressive 
tendencies  and  undergoes  a  cure  unaided  by  medication  may  be 
mentioned  the  writings  of  Leroux,  Cruveilheir,t  a^d  Rogee, 
who,  in  his  work,  J  makes  the  statement  that  in  fifty  out  of 
one  hundred  autopsies,  which  he  made  on  old  men,  he  found 
evidences  of  pulmonary  phthisis  which  had  been  completely 

*  De  la  Tuberculose  Chirurgicale,  etc.,  Paris,  1890,  p.  485. 

t  Anat.  Path.  Gen.,  T.  x,  p.  616. 

J  Arch.  Path.  Gen  de  Me'd.,  1829,  T.  v. 


253 

cured.  Boudet*  and  Gaucherf  studied  carefully  the  process 
of  spontaneous  cure  of  tubercle  by  cicatrization.  Similar  and 
other  observations  in  the  same  direction  were  made  by  Grisolle, 
Guencon  de  Mussy,  Lebert,  Jaccoud,  Herard,  Cornil,  Peter, 
and,  lastly,  the  work  of  Thavu.J 

Jeannel§  has  made  experimental  investigation  in  the  same 
direction,  concerning  the  curability  of  tuberculosis,  as  Gosselin. 

He  made  the  following  four  series  of  experiments : — 

1.  Local  treatment  alone. 

"2.  Local  and  general  treatment  combined. 

3.  General   treatment   alone  from   the  beginning  of  the 
disease. 

4.  General  treatment  alone  from  a  period  remote  from  the 
beginning  of  the  disease ;  that  is,  from  the  time  inoculation  was 
made. 

On  the  whole,  the  results  were  not  very  encouraging.  The 
local  treatment  alone  or  combined  with  general  treatment  did 
not  prevent  the  development  of  tuberculosis ;  all  of  the  inocu- 
lated rabbits  died  from  well-marked  tubercular  affections,  and 
the  treatment  did  not  even  retard  the  progress  of  the  disease  or 
postpone  the  fatal  termination.  General  treatment  alone,  inaugu- 
rated at  the  time  the  inoculation  was  made,  proved  also  ineffica- 
cious, and  Jeannel  even  intimates  that  the  treatment  by  iodoform 
ether  has  neither  the  power  to  cure  nor  to  retard  tuberculosis 
in  the  rabbit.  Finally,  general  treatment  alone,  instituted  at  a 
period  remote  from  the  beginning  of  the  disease,  was  a  com- 
plete failure  in  every  respect.  Remarking  how  these  results 
were  so  widely  at  variance  with  those  claimed  by  Gosselin, 
the  latter  replied  that  he  positively  maintained  the  assertion 
previously  made  concerning  the  curability  of  local  tuberculosis 
by  treatment  with  iodoform  injections.  He  at  the  same  time 

*  These  de  Paris,  1843. 

t  Archives  de  Physiologic,  1878. 

J  Clinique  Chir.  des  Mai.  Chron.,  1877. 

§  "  Recherches  sur  la  Generalisation  de  la  Tuberculose  Experimentale,"  Congres  de  la 
Tubereulose.  Paris,  p.  351.  "Nouvelles  recherches  experimentales  sur  la  tuberculose  et  sa 
curabilite,"  Etudes  sur  la  tuberculose,  fasc.  ii,  p.  416. 


254  TUBERCULOSIS   OF   THE    BONES   AND   JOINTS. 

insisted  that  generalization  of  tuberculosis  varies  with  the  place 
where  the  inoculation  is  made. 

The  discrepancy  of  the  views  entertained  by  these  French 
investigators  leaves  the  experimental  field  concerning  the  cura- 
bility of  tuberculosis  by  the  local  and  subcutaneous  use  of  iodo- 
form  open  for  future  research  to  determine  definitely  the  value 
of  this  remedy  in  the  treatment  of  this  disease. 


CHAPTER  XXIV. 

TREATMENT   or  TUBERCULOSIS  OF  JOINTS  BY   PARENCHYMATOUS 
AND  INTRA-ARTICULAR  INJECTIONS  (continued). 

Clinical  Results. — The  clinical  results  have  been  more  uni- 
formly in  support  of  the  antitubercular  action  of  iodoform  than 
the  conclusions  drawn  from  experimental  work.  The  iodoform 
treatment  of  tubercular  affections  of  bones  and  joints  found  an 
enthusiastic  advocate,  in  France,  in  the  person  of  Verneuil;* 
through  his  example  and  influence  it  found  ready  adoption  at 
once  in  different  parts  of  that  country  by  the  most  prominent 
surgeons. 

Vercheref  expresses  himself  as  highly  pleased  with  the 
results  obtained  by  injections  of  ethereal  solutions  of  iodoform, 
as  advised  by  Verneuil  a  year  after  the  latter  surgeon  published 
his  first  paper  on  the  subject. 

SegondJ  restricts  the  use  of  the  iodoform  treatment  to 
patients  greatly  debilitated  by  the  disease,  and  in  cases  in  which 
the  primary  disease  is  inaccessible  to  radical  measures. 

Barrette  §  reports  twenty-eight  observations  of  his  own,  with 
very  favorable  results.  Among  these  was  a  man,  aged  33,  with 
tubercular  osteomyelitis  of  the  fourth  rib,  complicated  by  in- 
cipient pulmonary  phthisis.  The  cold  abscess,  which  had  de- 
veloped in  connection  with  the  rib,  was  treated  by  iodoform 
injections,  and  the  local  lesion  was  cured. 

Two  cases  of  cold  abscess  originating  from  the  spine  were 
also  cured.  In  one  case,  in  which  an  abscess  started  from  a 
tubercular  focus,  after  resection  of  the  elbow,  the  injections 
were  followed  by  deatli  from  iodoform  intoxication.  The  ne- 
cropsy revealed  an  incurable  chronic  affection  of  the  kidneys. 

*  "Injections  d'ether  iodoforme  dans  les  absces  froids."  Revue  de  Chirurgie,  1885,  p.  428 
et  sequi. 

t  Revue  de  Chirurgie,  1886,  pp.  476-502. 

\  "Absces  Tuberculeux  de  la  Cuisse,  injections  d'ethor  iodoforme  on  operation  sanglante." 
Gazette  des  hopiteanx,  No.  146,  1887. 

§  "  Sur  le  traitement  des  manifestations  externes  de  la  tuberculose."  Congres  de  la  Tuber- 
culose,  p.  586. 

(255) 


256  TUBERCULOSIS   OF    THE    BONES    AND    JOINTS. 

Reclus,  *  in  giving  his  results  of  this  method  of  treating  tuber- 
cular affections,  reports  only  two  complete  failures ;  five  im- 
proved ;  meanwhile  two  died  of  slow  tubercular  lung  complica- 
tions. Eight  recovered  in  spite  of  large  collections  located 
where  operation  was  practically  impossible,  and  in  nine  cases 
the  final  outcome  could  not  be  learned.  He  injects  into  large 
abscesses  from  60  to  120  grammes  of  a  5-per-cent.  solution  of 
iodoform  in  ether.  The  injections  to  be  repeated  in  from  three 
to  four  weeks  ;  and  in  some  cases  the  injection  has  to  be  repeated 
a  third  and  a  fourth  time.  After  the  injections  the  abscess-wall-' 
becomes  greatly  disturbed  by  the  ether-gas ;  if  the  vitality  of 
the  overlying  skin  is  considerably  impaired,  necrosis  may  take 
place  from  the  pressure.  In  such  cases  the  ether-vapor  is  to  be 
removed  by  inserting  a  small  trocar.  In  a  few  cases  this  treat- 
ment was  followed  by  suppuration  and  the  formation  of  a  fistula, 
which,  however,  soon  healed.  He  is  of  the  opinion  that  in  all 
of  the  cases  in  which  a  cure  followed,  the  same  result  could  have 
been  obtained  by  incision  and  curetting,  but  the  latter  treatment 
would  have  required  more  time  and  would  have  left  unsightly 
scars.  In  favor  of  the  iodoform  treatment,  he  also  maintains 
that  it  is  less  likely  to  be  followed  by  a  relapse,  and  cites  Trelat, 
Guyon,  Bouilly,  Nelaton,  Richelot,  Quenu,  Peyrot,  and  Bruns 
as  entertaining  the  same  opinion. 

Tilanusf  studied  the  antiseptic  and  antibacillary  properties 
of  iodoform,  and  concludes  that  it  is  a  useful  remedy  in  the 
treatment  of  tuberculosis. 

VilleminJ  is  of  the  opinion  that  iodoform  is  deserving  of 
the  confidence  of  the  surgeons.  The  French  surgeons  have 
employed  almost  exclusively  the  ethereal  solutions  of  iodoform 
(o  to  100),  and  we  hear  of  cases  in  which,  like  in  some  of 
the  experiments  on  animals,  the  injections  caused  a  violent 
local  inflammation  and  even  gangrene.  The  injection  is  also 

*  Gazette  Hebdomadaire,  1887. 

t  '•  Proprietes  de  1'iodoforme."    Revue  de  Uhirurgie  fevrier,  1890. 

J  Etude  experimentale  de  1'action  de  quelques  agents  chimiques  sur  le  development  du 
bacille  de  la  tuberculose,  1888. 


PARENCHYMATOUS    AND    INTRA-ARTICULAR    INJECTIONS.       257 

painful,  as  the  temperature  of  the  body  is  sufficiently  high  to 
vaporize  the  ether  in  a  very  short  time  after  its  injection,  which 
causes  painful  and  sometimes  dangerous  tension  in  the  joint  or 
abscess.  It  appears  also  that  iodoform  intoxication  occurs  more 
frequently  when  the  ethereal  solution  is  used  than  when  the 
iodoform  is  injected  in  the  form  of  an  emulsion  in  glycerin  or 
in  olive-oil.  A  case  of  death  from  iodoform  intoxication  was 
alluded  to  above,  and  another  occurred  in  the  practice  of  Barvis.* 

The  patient  was  a  soldier,  aged  24,  the  subject  of  a  large 
cold  abscess  in  the  region  of  the  left  wall  of  the  chest.  This 
was  punctured,  and,  after  evacuation  of  its  contents,  from  50  to 
60  grammes  of  a  5-per-cent.  ethereal  solution  of  iodoform  were 
injected.  Immediately  after  injection  the  patient  went  into  col- 
lapse, and  it  is  possible  that  some  of  the  fluid  was  injected  into 
the  pleural  cavity.  In  explanation  of  the  sudden  death  it  may 
be  suspected  that  a  small  quantity  of  the  ether- vapor  was  forced 
into  the  venous  circulation,  and  that  the  collapse  was  caused  by 
ether-vapor  embolism ;  but  Barvis  attributes  death  in  this  case 
to  acute  iodoform  intoxication.  In  view  of  the  fact  that  ether- 
iodoform  injections  are  always  productive  of  pain,  and  not  in- 
frequently produce  intense  local  reaction,  and  that  the  ether 
used  may  become  a  source  of  danger,  and  that  they  are  more 
liable  to  give  rise  to  intoxication  than  when  iodoform-glycerin 
emulsion  is  used,  the  latter  preparation  should  be  used  exclu- 
sively. In  Germany  the  latter  method  of  administration  is  used 
almost  exclusively. 

Brans  uses  a  10-per-cent.  mixture  of  iodoform  in  glycerin 
or  olive-oil,  always  taking  the  precaution  to  sterilize  the  mixture. 
Krause  recommends  the  following  mixture : — 

R  Iodoform.  subt.  pulveris 50.00 

Muc'tl.  gumnii  arab., 2.30 

Glycerini, 83.00 

Aq.  destillat q.  s.  ad    500.00 

Sig. :  Ten-per-cent.  iodoform  mixture.     To  this  mixture   he   adds   1   per 
cent,  of  pure  carbolic  acid, 

*  "Du  traitement  des  Abscfess  froids,  Intoxication  iodoformique  mortelle."    Arch,  de 
Med.  et  de  Pharmacie,  T.  xvi,  No.  8, 1890. 

IT 


258  TUBERCULOSIS   OF   THE    BONES    AND    JOINTS. 

Whatever  formula  for  the  solution  is  selected,  not  more 
than  half  a  drachm  of  the  iodoform  should  be  injected  at  the 
first  time,  and  in  children  even  less.  If  this  dose  does  not  pro- 
duce any  unpleasant  symptoms  it  may  be  increased  the  next 
time  the  operation  is  repeated.  If  used  in  this  manner  the  risk 
of  iodoform  intoxication  appears  to  be  nil,  or  at  least  very 
remote,  as  not  a  single  instance  was  observed  in  one  hundred 
and  eight  cases  treated  in  the  Tubingen  clinic  by  Bruns.  The 
best  results  with  iodoform  injections  come  from  the  Halle  and 
Tubingen  clinics.  This  is  undoubtedly  owing  to  the  fact  that 
in  these  institutions  this  treatment  has  been  very  extensively 
used,  and  the  large  experience  thus  gained  has  enabled  the  sur- 
geons to  make  a  proper  selection  of  cases  and  apply  the  treatment 
in  the  most  efficient  manner. 

Bruns*  injects,  every  two  weeks,  a  mixture  composed  of 
10  parts  of  iodoform,  50  of  glycerin,  and  50  of  distilled  water. 
In  his  first  report  he  states  that  of  fifty-four  cases  of  tubercular 
abscess  forty  have  recovered  under  this  treatment. 

In  a  later  publication  the  same  author  f  asserts  that  the 
antitubercular  action  of  iodoform  has  been  demonstrated.  In 
order,  however,  for  this  drug  to  exert  its  specific  action  it  is 
necessary  that  the  whole  interior  surface  of  a  joint  or  tubercu- 
lar abscess  should  be  acted  upon,  and  the  action  should  be 
uninterrupted  and  continued  for  a  long  time.  The  curative 
effect  often  only  becomes  apparent  after  three  or  four  months, 
but  from  this  time  the  abscess  gradually  disappears.  Of  one 
hundred  cases  of  tubercular  abscess  treated  in  his  clinic  during 
the  last  five  years  80  per  cent,  were  cured,  and  during  four 
years  fifty  cases  of  joint  tuberculosis  were  also  cured.  He  uses 
now  a  10-  to  20-per-cent.  mixture  of  iodoform  in  pure  glycerin 
or  olive-oil,  prepared  fresh  and  thoroughly  sterilized  before  each 
injection. 

»  "Ueber  die  antitnberculose  Wirkung  des  lodoforms."  Verh.  der  Deutschen  Gesell- 
schaft,  f.  Chirurgie,  1877. 

t  "Ueber  die  Behandluiig  tuberculoser  Abscesse  und  Gelenkerkrankungen  mit  lodoform- 
injectionen."  Boitrage  zur  klinischen  Chirurgie,  vi,  3,  p.  639,  1890. 


PARENCHYMATOUS    AND   INTRA-ARTICULAR   INJECTIONS.       259 

In  the  case  of  fungous  joints  he  makes  the  injection  not 
only  into  the  cavity  of  the  joint,  but  also  into  the  thickened 
capsule,  making  the  puncture  at  different  points,  and  injecting 
from  2  to  6  centimetres  of  the  mixture.  In  tubercular  hydrops 
and  tubercular  abscess  the  fluid  or  softened  contents  are  first 
removed,  whereupon  10  to  30  centimetres  of  the  mixture  are 
injected. 

Neither  pain  nor  symptoms  of  local  irritation  follow  the 
procedure,  but  the  temperature  usually  shows'  a  rise  of  from  one 
to  two  degrees,  which,  however,  disappears  after  a  few  days. 
He  does  not  immobilize  the  injected  joints.  He  has  never  met 
with  cases  of  iodoform  intoxication  from  the  injections.  Paren- 
chymatous  injections  are  to  be  repeated  every  eight  days,  intra- 
articular  injections  every  two  to  four  weeks.  Symptoms  of 
improvement  seldom  appear  before  the  expiration  of  six  to 
eight  weeks,  although  the  pain  diminished  at  an  earlier  date. 

Shrinking  of 'the  fungous  capsule  is  the  surest  indication 
of  beginning  improvement.  In  children  suffering  from  tubercu- 
losis of  joints  the  functional  result  is  frequently  perfect  if  -the 
treatment  is  begun  before  the  disease  has  resulted  in  exten- 
sive destruction  of  the  soft  structures  of  the  joint.  In  adults  the 
best  results  often  consist  in  a  useful  but  partially  or  completely 
ankylosed  limb. 

Wendelstadt*  uses  a  mixture  of  iodoform  in  olive-oil  in  the 
proportion  of  5  to  25.  He  insists  that  the  mixture  should  be 
prepared  fresh  every  time,  as  in  mixtures  kept  for  some  time 
free  iodine  is  generated,  the  presence  of  which  can  be  recognized 
by  the  mixture  presenting  a  brownish-red  color. 

As  a  parenchymatous  injection,  he  throws  from  2  to  3  centi- 
metres of  this  mixture  into  the  tissues  with  an  ordinary  Pravaz 
syringe.  The  injection  is  repeated  every  eight  days ;  the  punc- 
ture should  always  be  made  at  a  different  point  in  order  to  reach, 
successively,  different  parts  of  the  focus. 

*  "  Zur  Behandlung  der  tuberculosen  Knochen  und  Gelenkerkrankungen  durch  paren- 
chymatose  Injectionen  von  lodoformol."    Centralblatt  f.  Chirurgie,  No  38, 1889. 


260  TUBERCULOSIS   OF   THE    BONES    AND    JOINTS. 

In  several  cases  he  observed  a  rise  in  the  temperature  to 
40°  C.  the  same  day,  but  the  febrile  reaction  always  subsided 
in  a  short  time.  This  method  was  applied  in  109  cases  of  local 
tuberculosis ;  of  this  number,  28  were  later  treated  by  incisions 
and  evidement.  A  permanent  cure  was  obtained  in  36 ;  im- 
proved, 37 ;  not  much  benefited,  1 2,  and  24  remained  under 
treatment. 

Andrassy*  gives  the  particulars  of  the  22  cases  of  cold  ab- 
scesses treated  by  iodoform  injection  that  were  first  reported 
from  the  Tubingen  clinic  by  Bruns.  Of  this  number,  20  were 
perfectly  and  permanently  cured.  In  one  case  the  abscess  had 
to  be  opened.  The  largest  dose  of  iodoform  used  was  10 
grammes.  No  symptoms  of  intoxication  were  observed  in  any 
of  these  cases,  but  occasionally  a  considerable  rise  in  tempera- 
ture followed  the  procedure.  In  most  cases  the  operation  had 
to  be  repeated  two  or  three  times  at  intervals  of  two  weeks. 
The  healing  process  was  generally  completed  in  from  one-half 
to  two  and  one-half  months. 

Billrothf  uses  a  10-per-cent.  iodoform-glycerin  emulsion. 
The  tubercular  joint  or  abscess  is  evacuated  and  from  40  to  50 
grammes  of  the  mixture  are  injected.  The  injection  is  not  re- 
peated until  the  urine  no  longer  reacts  to  the  iodine  test. 

During  two  years,  KrauseJ  treated  tubercular  affections  of 
the  following  joints  by  mtra-articular  injections  of  iodoform  : — 

Knee-joint, .        .        .36 

Hip-joint,     .  .        .      .•<•','.' 13 

Tarsal  joint,  ;        .        . ;       .        ...        .        .        .6 

Wrist-joint,  .        ...        ...        .        .5 

Elbow-joint,  -.        .       Y       .        \ ;••••;  _    . .       .        .      1 

The  treatment  was  not  completed  in  all  of  these  cases,  but 
a  cure  had  been  effected  in  the  following : — 

*  "  Beitrage  zur  Behandlnng  der  kalten  Abscesse,  insbesondere  mittelst  lodoforminjec- 

tionen."    Bruns'  Beitrage  zur  klinischeii  Ouirurgie,  ii,  1887. 

t  "  Ueber  die  Behandlung  kalter  Abscesse  in  tuberculoser  Caries  mit  lodoform  Emulsion." 
f'Ueber  den  heutigen  Standpunkt  in  der  Behandlung  der  tuberculosen  Knochen  und 

Qelenk  Krankheiten."    Berl.  klin.  Wochenschrift,  No.  49,  1890. 


PARENCHYMATOUS   AND   IN TRA- ARTICULAR    INJECTIONS.      261 

Knee-joint,  .        .        .        ;        .  •  .  .  .  .15 

Hip-joint,  .  .        .        ....  .  .  .  .      4 

Tarsal  joint,  ...        .        .  .  .  .  .1 

Wrist-joint,  '.        .        .        .        .  .  .  .  .      3 

Three  of  the  cases  that  were  cured  were  sent  to  the  clinic 
to  undergo  an  amputation. 

Although  in  the  cases  where  the  wrist-joint  was  involved 
the  treatment-  failed  in  restoring  motion,  it  made  the  fingers 
more  movable  and  useful.  In  the  hip-joint  cases,  recovery 
usually  resulted  in  almost  total  ankylosis. 

This  was  evidently  due  to  the  fact  that  the  severest  cases 
were  subjected  to  this  treatment,  and  much  better  functional 
results  can  be  expected  if  this  treatment  is  commenced  during 
the  early  stages  of  the  disease. 

Improvement  was  noted  in  nearly  all  cases  that  remained 
under  treatment.  The  best  results  were  realized  from  the 
treatment  in  tuberculosis  of  the  knee-  and  wrist-  joints.  He 
recommends  that,  if  the  cannula  of  a  large  trocar  is  not  large 
enough  through  which  the  joint  can  be  completely  emptied  of 
its  contents,  an  incision  should  be  made  for  this  purpose,  and 
the  wound  sutured  before  the  injection  is  made. 

Of  the  cold  abscesses  which  were  subjected  to  treatment  by 
iodoform  injection,  50  per  cent,  were  cured.  He  believes  that 
intoxication  symptoms  are  not  produced  by  using  emulsion  of 
iodoform,  because  none  of  the  iodoform  is  in  solution,  and  on 
this  account  absorption  is  very  slow.  He  has  injected  the  emul- 
sion which  he  uses  in  doses  varying  from  5  to  80  grammes. 
The  injections  never  caused  much  pain,  but  were  often  followed 
by  a  rise  of  temperature  for  a  short  time.  The  first  symptoms 
which  denote  that  improvement  is  taking  place  are  lessening 
of  pain  and  diminution  of  swelling.  Peri-articular  abscesses 
recurred  several  times  after  they  were  apparently  cured,  and  re- 
quired repetition  of  treatment. 

Trendelenburg  has  treated  one  hundred  and  thirty-five 
cases,  of  all  grades  of  severity,  by  the  injection  method,  making 
one  injection  of  5  grammes  every  eight  days.  The  most  striking 


262  TUBERCULOSIS    OF    THE    BONES   AND    JOINTS. 

results  were  obtained  in  wrist-joint  tuberculosis  in  adults, — a 
disease  which  usually  gives  a  bad  prognosis  and  frequently 
necessitates  amputation.  In  68  per  cent,  of  all  cases,  the  treat- 
ment had  a  favorable  effect. 

Immediate  and  Remote  Dangers  Attending  lodoform  In- 
jections.— The  dangers  attending  the  treatment  of  tubercular 
affections  of  bones  and  joints  by  iodoform  injections  may  arise 
from  iodoform  intoxication,  the  action  of  the  menstruum  em- 
ployed, secondary  infection,  and  injury  of  important  parts  by 
the  instrument  used  in  making  the  puncture. 

In  a  case  of  BoeckePs,*  the  patient  died  during  the  opera- 
tion. It  was  found  that  the  abscess  communicated  with  the 
subclavian  artery.  In  three  of  Konig'sf  cases  the  puncture  of 
the  abscess  was  followed  by  profuse  haemorrhage,  due  to  arterial 
erosion.  The  arteries  involved  were  the  gluteal,  the  deep  femoral, 
and  the  external  plantar.  These  had  to  be  ligated.  A  similar 
complication  occurred  in  two  cases  under  the  care  of  Lindner:^: 
one  of  fatal  haemorrhage  from  the  femoral  and  the  other  from 
the  iliac  vein. 

Dollinger§  does  not  approve  of  the  iodoform-ether  injec- 
tions as  advised  by  Verneuil,  as  he  has  found  in  his  experience 
that  in  children  they  did  not  induce  recovery  in  a  single  case. 
He  not  only  regards  them  useless,  but  harmful,  as  the  injection 
of  even  small  doses  produced  deafness,  headache,  and  nausea, 
while  larger  quantities  were  followed  by  loss  of  consciousness, 
impaired  respiration,  and  acute  cystitis.  At  the  moment  of  in- 
jection some  headache  may  be  felt,  and  there  may  be  an  evening 
rise  of  temperature  of  3  to  4  degrees.  The  rapid  evaporation 
of  the  ether  may  cause  necrosis  of  the  abscess-wall,  and  if,  for 
example,  psoas  abscess  from  rapid  overdistension  should  rupture 
into  the  peritoneal  cavity,  death  might  result  from  such  injec- 
tions from  septic  peritonitis. 

•London  Medical  Record,  1889. 
t  Centralblatt  f.  die  Kesammte  Therapie,  1887. 
I  Deutsche  Med.  Wochenschrift,  1887. 

§"Beitragje  zur  lodo form-ether  behandlung  der  tuberculosen  Knochen  entziindung." 
Centralblatt  f.  Chirurgie,  May  18,  1889. 


PARENCHYMATOUS    AND   IN TR A- ARTICULAR    INJECTIONS.       263 

Heusner*  reports  a  case  of  iodoform  intoxication  caused 
by  an  intra-articular  injection  of  0.1  gramme  of  iodoform  in 
glycerin.  Bramann  observed  quite  grave  symptoms  of  intoxi- 
cation after  an  injection  containing  2.0  grammes  of  iodoform. 
The  patient  was  a  boy.  Later,  the  injection  of  the  same  amount 
produced  no  untoward  symptoms. 

Trendelenburg  first  used  iodoform-ether,  but  in  a  short  time 
the  injection  produced  gangrene  of  the  overlying  abscess-wall 
in  three  cases,  and  after  that  he  has  used  the  emulsion-  exclu- 
sively and  has  not  observed  such  a  result  since.  Gangrene  of 
the  overlying  tissues  and  iodoform  intoxication  have  only  been 
observed  after  iodoform-ether  injections ;  the  first  is  caused  by 
the  overdistension  resulting  from  vaporization  of  the  ether,  and 
the  latter  is  due  to  rapid  absorption  of  the  iodoform  kept  in  solu- 
tion by  the  ether.  Another  possible  remote  source  of  danger 
attending  the  injection  of  the  ethereal  solution  is  the  entrance 
of  ether-vapor  into  one  of  the  veins,  causing  death  from  ether- 
embolism. 

The  dangers  just  enumerated  do  not  belong  to  injections  of 
iodoform  held  in  suspension  in  glycerin  or  olive-oil.  Accidental 
infection,  which  lias  occasionally  occurred  during  or  after  the 
injection,  is,  of  course,  caused  by  a  faulty  antisepsis,  and  has 
happened  from  the  use  of  iodoform  by  parenchymatous  and 
intra-articular  injections,  irrespective  of  the  menstruum  used. 
If  such  an  accident  take  place,  it  will  become  necessary  to  make 
a  puncture  with  a  large  trocar  and  evacuate  the  pus  through 
the  cannula,  and  resort  at  once  to  irrigation  with  a  3-per-cent. 
solution  of  boric  acid,  or  treatment  by  incision  and  drainage 
may  be  required.  Dangerous  hemorrhage  is  occasionally  en- 
countered in  treating  tubercular  abscesses  by  incision  and 
scraping  when  a  vessel  of  considerable  size  has  become  eroded, 
and  the  possible  occurrence  of  this  accident  does  not  militate 
against  the  treatment  by  iodoform  injections. 

Action  of  Iodoform  on  Tubercular  Tissue. — If  iodoform,  in 

*  Berl.  klin.  Wochenschrift,  October  5,  1891. 


264  TUBERCULOSIS   OF   THE    BONES   AND   JOINTS. 

the  form  of  an  emulsion,  is  injected  into  an  empty  tubercular 
joint  or  abscess,  and  an  effort  made  to  diffuse  it  over  the  whole 
interior  surface  by  passive  motion,  pressure,  and  rubbing,  the 
fine  particles  of  iodoform  will  soon  be  equally  distributed  over 
the  entire  surface  clinging  to  the  granulations,  fibrinous  masses, 
or  the  cheesy  material  lining  the  cavity.  The  iodoform  pro- 
duces no  violent  irritation  ;  its  action  on  the  tissues  is  mildly 
stimulating.  The  re-accumulation  of  fluid  in  the  joint  or  tuber- 
cular pus  in  the  abscess  is  slow,  and  if  the  procedure  is  repeated 
after  eight  days  to  two  weeks  the  fluid  withdrawn  will  contain 
particles  of  iodoform,  showing  that  the  absorption  of  this  sub- 
stance, when  not  applied  in  solution,  is  very  slow.  At  the  same 
time  the  fluid  will  have  changed  its  character  somewhat,  con- 
taining elements  the  presence  of  which  indicates  that  remnants 
of  dead  tissue,  products  of  coagulation  necrosis,  are  being  thrown 
off,  and  that  a  reparative  process  has  been  initiated.  The  first 
effect  of  the  iodoform  on  the  tissues  lining  the  joint  or  cavity  is 
to  bring  about  rapid  disintegration  of  the  tubercular  product, 
which  then  is  displaced  by  a  layer  of  active  and  very  vascular 
granulations. 

Brims  and  Nauwerk*  incised  tubercular  abscesses  treated 
by  iodoform  injections  at  different  intervals  after  the  injection 
and  extirpated  pieces  of  the  abscess-wall  for  microscopical  ex- 
amination. A  few  weeks  after  injection  they  found  that  the 
tubercle  bacilli  had  disappeared,  the  miliary  tubercles  softened 
by  infiltration  with  round-cells  and  cedematous  inhibition  of  a 
serous  fluid ;  further  on  the  tubercles  disappeared  by  fatty  degen- 
eration of  the  cells  and  liquefaction  of  the  cellular  detritus. 
Hand  in  hand  with  the  degeneration  and  liquefaction  of  the 
tubercular  product  could  be  witnessed,  in  the  adjacent  tissues, 
a  process  of  repair,  in  the  shape  of  a  wall  of  granulation  tissue, 
which  formed  a  line  of  demarcation  between  the  healthy  and 
diseased  tissue,  which  consumed  in  part  the  dead  sterile  tuber- 

*  "  Ueber  die  antituberculose  Wirkung  (les  lodofovms,  Klirrsche  und  Histologische  Unter- 
suchungen.  "    Beitrage  zur  Klinischen  Chinugie,  UL    Tubingen,  1887. 


PARENCHYMATOUS    AND    INTRA-ARTICULAR    INJECTIONS.       265 

cular  tissue  and  detached  the  balance.  As  soon  as  the  dead 
tissue  was  disposed  of  by  absorption  the  granulations  began  to 
cicatrize,  and  were  gradually  converted  into  connective  tissue, 
and  with  this  change  the  process  of  the  healing  was  completed. 
Krause  made  similar  examinations  and  corroborates  the  obser- 
vations made  by  Bruns  and  Nauwerk.  That  the  curative  effect 
of  iodoform,  in  the  treatment  of  tubercular  joints  and  abscesses, 
is  not  owing  to  the  mere  puncture  and  evacuation,  but  is 
brought  about  by  the  specific  action  of  iodoform  on  the  tuber- 
cular products,  there  can  be  no  doubt,  as  tapping  for  these  con- 
ditions was  employed  long  before  iodoform  was  used  in  surgery, 
but  this  procedure  seldom  yielded  more  than  temporary  relief. 
Stockma  treated  five  tubercular  abscesses  by  tapping  alone,  but 
always  with  negative  results.  If  he  injected  the  contents  of 
tubercular  abscesses,  treated  by  different  methods,  into  the  an- 
terior chamber  of  the  eye  in  rabbits  the  result  was  always  posi- 
tive except  in  the  case  of  abscesses  treated  by  iodoform  injec- 
tions, in  which  a  sufficient  time  had  elapsed  for  the  iodoform  to 
exert  its  specific  antibacillary  effect.  Iodoform  exercises  a  double 
therapeutic  action  on  tubercular  tissue  when  used  by  parenchy- 
matous  or  intra-articular.  injections;  it  destroys  the  bacillus  of 
tuberculosis  and  aids  the  removal  of  the  dead  sterile  tissue,  and 
favors  the  subsequent  reparative  process  by  its  stimulating  action 
on  the  surrounding  healthy  tissue, — properties  not  possessed,  to 
the  same  degree,  by  any  other  as  yet  known  substance. 

Indications. — The  curative  power  of  iodoform  injections 
has  so  far  been  most  manifest  in  the  treatment  of  heretofore 
most  hopeless  cases  of  surgical  tuberculosis, — tubercular  abscess 
in  connection  with  an  inaccessible  osseous  focus.  One  of  the 
most  brilliant  achievements  of  modern  surgery  is  the  successful 
treatment  of  tubercular  abscesses  developing  in  the  course  of 
tubercular  spondylitis  by  iodoform  injections.  Statistics  show 
that  more  than  50  per  cent,  of  such  cases  are  amenable  to  this 
method  of  treatment.  In  the  successful  cases  not  only  the 
abscess  but  the  primary  bone-lesion  is  also  cured. 


266    '  TUBERCULOSIS   OF   THE    BONES    AND    JOINTS. 

One  of  the  most  striking  illustrations  of  the  efficiency  of 
iodoform  treatment  in  these  grave  cases  recently  came  under  my 
observation.  The  patient  was  a  delicate  girl  aged  8,  who  had 
suffered  from  a  tubercular  spondylitis  at  the  junction  of  the  last 
dorsal  with  the  first  lumbar  vertebra  for  six  months.  Slight 
angular  posterior  curvature.  Within  two  months  an  enormous 
abscess  developed  in  the  right  lumbar  and  iliac  regions.  Below 
the  abscess  extended  as  far  as  Poupart's  ligament,  above  to  the 
last  rib.  The  abscess  was  very  prominent  in  the  lumbar  and  in- 
guinal regions.  The  child  had  a  temperature  of  104°  F.  every 
evening.  The  abscess  was  punctured,  under  strict  antiseptic  pre- 
cautions, in  the  lumbar  region,  and  nearly  two  quarts  of  tuber- 
cular pus  evacuated.  The  abscess-cavity  was  irrigated  with  a 
3-per-cent.  boric-acid  solution  until  the  fluid  returned  perfectly 
clear,  and  2  ounces  of  a  10-per-cent.  mixture  of  iodoform  in 
glycerin  injected.  The  puncture  was  sealed  with  a  pledget  of 
antiseptic  cotton  and  iodoform  collodium. 

The  first  injection  had  no  effect  in  reducing  the  tempera- 
ture; at  the  end  of  a  week  it  was  repeated,  and  about  half  as 
much  tubercular  pus  removed.  The  temperature,  in  a  few  days 
alter  the  second  injection,  was  normal.  The  third  and  last  in- 
jection was  made  four  weeks  after  the  first.  At  this  time  only 
about  six  ounces  of  a  viscid  fluid  were  removed.  The  child  im- 
proved in  general  health,  and  after  this  time  no  re-accumulation 
of  fluid  occurred.  At  the  present  time,  six  months  after  treat- 
ment was  commenced,  the  child  is  wearing  a  plaster-of-Paris 
corset,  and  appears  to  be  in  perfect  health. 

No  one  who  is  familar  with  the  efficacy  of  iodoform  injec- 
tions in  the  treatment  of  tubercular  abscesses  would  or  should 
neglect  to  resort  to  it  when  called  upon  to  treat  tubercular 
abscess  in  communication  with  an  inaccessible  primary  tuber- 
cular focus.  This  applies  with  special  force  to  abscesses  devel- 
oping in  connection  with  tuberculosis  of  the  vertebra  and  some 
of  the  pelvic  bones. 

This  treatment  is  again  applicable,  and  has  yielded  excel- 


PARENCHYMATOUS    AND    INTRA-ARTICULAR    INJECTIONS.       267 

lent  results,  in  tuberculosis  of  the  knee  and  other  readily  acces- 
sible joints,  with  or  without  the  formation  of  para-articular 
abscesses. 

The  treatment  is  most  useful  if  the  joint  is  distended  with 
fluid,  as  under  such  circumstances,  after  the  removal  of  the  fluid, 
the  iodoform  can  be  brought  in  contact  with  the  entire  surface 
of  the  cavity.  This  is  often  impossible  if  portions  of  the  joint 
have  been  shut  out  by  intra-articular  adhesions.  Irrigation  of 
the  joint  should  never  be  omitted  if  it  contain  pus,  flakes  of 
lymph,  or  detached,  broken-down  fragments  of  tubercular  tissue, 
and  it  is  in  such  cases  that  the  cannula  of  even  a  large  trocar  is 
often  not  of  sufficient  size  to  evacuate  the  joint  or  abscess  prop- 
erly, and  that  the  puncture  has  to  be  followed  by  an  incision 
large  enough  to  meet  the  requirements. 

If  the  joint  contain  no  fluid  ft  is  difficult  and  usually  im- 
possible to  reach  all  of  the  infected  tissues  by  an  intra-articular 
injection,  and  it  is  in  such  cases  that  it  must  be  combined  with 
parenchymatous  injections,  and  the  site  of  puncture  changed  at 
each  operation.  As  no  fluid  is  to  be  removed,  and  no  irrigation 
to  be  made  under  such  circumstances,  the  necessary  amount  of 
iodoform  emulsion  is  thrown  into  the  joint  and  into  the  thick- 
ened fungous  capsule  with  an  ordinary  Pravaz  syringe,  supplied 
with  a  large  needle.  The  puncture  is  made  at  different  points 
every  time  the  procedure  is  repeated.  It  cannot  be  expected 
that  a  cure  can  be  effected  by  this  method  of  treatment  if  the 
primary  focus  contain  large  masses  of  cheesy  material,  or  a 
sequestrum  of  considerable  size.  But  even  in  such  cases,  if  the 
injections  are  made  with  the  requisite  degree  of  care,  the  treat- 
ment is  harmless,  and  results  in  great  benefit  in  preparing  the 
parts  for  subsequent  surgical  treatment  by  operation. 

Points  to  be  Remembered  in  Making  Intra-articular  and 
Parencliymatoiis  Injections. — The  strictest  antiseptic  precautions 
must  be  practiced  in  making  the  injections,  as  neglect  in  this 
direction  would  not  only  interfere  with  an  ideal  result  of  the 
treatment,  but  would  expose  the  part  and  the  patient  to  the 


268  TUBERCULOSIS   OP   THE    BONES   AND   JOINTS. 

risks  and  dangers  incident  to  a  suppurative  inflammation,  with 
all  its  immediate  and  remote  consequences.  The  surface  where 
the  puncture  is  to  be  made  should  be  shaved  and  thoroughly 
scrubbed  with  hot  water  and  potash  soap,  and  carefully  disin- 
fected by  washing  with  an  antiseptic  solution,  and  lastly  with 
pure  alcohol.  The  trocar  should  be  sterilized  by  boiling,  or 
passing  it  slowly  through  the  flame  of  an  alcohol-lamp.  The 
emulsion  must  be  prepared  fresh  and  sterilized.  If  a  syringe 
is  used  for  making  the  injection,  it  should  be  one  with  an  asbes- 
tos disc  for  the  piston  and  kept  in  an  aseptic  condition.  If  a 
rubber  bulb  and  rubber  tubing  is  employed,  these  must  be  steril- 
ized. The  point  where  the  puncture  should  be  made  in  oper- 
ating on  the  different  large  joints  has  already  been  described. 
The  cardinal  rule  in  all  operations  should  be  to  select  the  short- 
est route  from  the  surface  into  the  different  joints,  and  at  a 
point  where  no  important  structures  will  come  into  the  line  of 
the  proposed  puncture.  In  injecting  a  tubercular  abscess  the 
puncture  should  not  be  made  where  the  abscess-wall  is  thinnest, 
but  some  distance  from  the  most  prominent  point  of  the  swelling, 
so  that  the  puncture  will  be  made  through  healthy  skin,  and 
not  through  tissues  reduced  in  vitality  from  the  long-continued 
pressure  from  beneath.  Before  the  puncture  is  made  the  skin 
is  drawn  to  one  side  so  that  after  the  removal  of  the  cannula  the 
puncture  in  the  deep  tissues  may  be  subcutaneous. 

The  ethereal  solution  of  iodoform  should  never  be  em- 
ployed, as  its  use  is  attended  by  greater  immediate  and  remote 
risks  than  if  the  iodoform  is  used  in  suspension  in  a  non- volatile 
menstruum. 

The  best  method  of  using  the  iodoform  is  a  10-per-cent. 
mixture  in  glycerin  or  olive-oil.  The  quantity  of  the  mixture 
to  be  injected  must  vary  somewhat  according  to  the  age  of  the 
patient  and  the  size  of  the  tubercular  focus.  From  3  drachms 
to  an  ounce  is  the  average  dose.  In  injecting  a  tubercular  joint, 
which  contains  fluid  or  a  tubercular  abscess,  irrigation  with  a 
3-per-cent.  solution  of  boric  acid  should  be  employed  until  the 


PARENCHTMATOUS    AND    INTRA-ARTICULAR   INJECTIONS.      269 

fluid  returns  perfectly  clear  before  the  iodoform  injection  is 
made.  If  the  joint  or  abscess-cavity  contain  broken-down 
tubercular  products,  which  cannot  be  removed  through  a  large 
cannula,  the  joint  or  abscess  should  be  freely  incised,  the  interior 
scraped  and  rubbed  out  with  iodoform  gauze,  wound  sutured, 
and  then  the  injection  made, — a  plan  of  treatment  practiced  with 
great  success  by  Billroth. 

In  making  parenchymatous  injections  the  needle  should  be 
inserted  in  different  directions  without  removing  it  completely, 
and  the  injection  made  at  as  many  points  as  possible  in  order 
to  saturate  as  large  a  territory  as  possible  of  the  infected  tissues. 
If  the  procedure  is  to  be  repeated  the  puncture  is  made  some 
distance  from  the  first  so  as  to  medicate  a  new  area  of  tubercular 
tissue. 

After  the  cannula  is  withdrawn  the  puncture  in  the  skin 
should  be  carefully  sealed  with  a  pledget  of  aseptic  cotton  and 
iodoform  collodium.  Mechanical  diffusion  of  the  injected  ma- 
terial should  be  secured  after  the  injection  by  kneading,  com- 
pressing, and  rubbing  the  parts,  and  by  making  passive  motion. 
The  injection  is  not  to  be  repeated  oftener  than  every  eight 
days  to  two  weeks,  and  the  treatment  continued  until  the  tuber- 
cular material  has  been  removed  and  healing  by  cicatrization 
is  in  progress. 

In  the  treatment  of  tubercular  joints  by  iodoform  injections, 
immobilization  is  only  necessary  if  active  motion  of  the  joint 
is  productive  of  great  pain.  In  tubercular  spondylitis,  with 
abscess,  the  iodoform  treatment  should  be  combined  with  the 
necessary  orthopaedic  treatment.  In  tuberculosis  of  bones  and 
joints,  with  a  large  caseous  mass  or  a  sequestration  of  consid- 
erable size  at  the  primary  focus,  the  iodoform  treatment  cannot 
take  the  place  of  mechanical  removal  of  the  infected  and  dead 
tissue,  but  is  often  of  great  value  as  a  preliminary  measure  to 
prepare  the  way  for  a  radical  operation. 

Cases  of  Tuberculosis  of  Bones  and  Joints  Recently  Treated 
by  Iodoform  Injections  in  the  Surgical  Clinic  of  Rush  Medical 


270  TUBERCULOSIS   OF    THE   BONES    AND   JOINTS. 

College. — The  most  brilliant  result  of  treatment  by  iodoform 
injections  that  came  under  my  own  personal  observation  was  the 
case  of  tubercular  spondylitis  reported  on  page  266.  The  local 
and  general  improvement  was  manifest  after  the  second  injec- 
tion, and  complete  cure,  not  only  of  the  enormous  abscess,  but 
also  of  the  primary  bone-lesion,  was  realized  in  less  than  three 
months. 

The  cases  reported  below  were  treated  in  the  clinic  of  Rush 
Medical  College  since  April,  1891.  In  some  of  the  cases  the 
ultimate  result  of  the  treatment  could  not  be  ascertained,  as  the 
patients  failed  to  report.  A  10-per-cent.  emulsion  of  iodoform 
in  glycerin  was  the  preparation  used  exclusively.  The  intra- 
articular  injections  were  made  with  a  two-ounce  glass  syringe, 
which  was  connected  with  the  cannula,  after  withdrawal  of  fluid, 
or,  in  case  the  joint  was  irrigated  with  a  solution  of  boric  acid 
after  completion  of  this  procedure,  by  a  piece  of  aseptic  rubber 
tubing  which  was  tied  firmly  over  the  distal  end  of  the  cannula 
and  the  nozzle  of  the  syringe.  Special  care  was  exercised  to 
prevent  the  entrance  of  air  into  the  joint.  As  a  rule,  the  pa- 
tients were  permitted  to  use  the  limb  moderately  during  the 
entire  treatment.  An  exception  to  this  rule  was  made  in  the 
cases  of  tuberculosis  of  the  hip-joint,  and  in  affections  of  the 
knee-joint  when  the  joint  was  much  contracted. 

In  no  case  was  the  injection  followed  by  suppuration,  in- 
toxication, or  any  other  immediate  or  remote  untoward  symp- 
toms. As  a  rule,  the  pain  following  the  injection  was  slight 
and  of  short  duration.  The  injection  was  always  followed  by 
some  swelling,  which  reached  its  maximum  about  the  second 
day.  Improvement  of  the  joint-lesion  was  always  announced 
by  a  change  in  the  character  of  the  effusion  in  the  cases  in 
which  this  condition  of  the  joint  existed.  If  the  joint  or  ab- 
scess contained  tubercular  pus,  the  first  change  noticed  was 
gradual  disappearance  of  the  solid  portion  of  the  fluid,  such  as 
shreds  of  lymph  and  fragments  of  tubercular  tissue;  at  the  same 
time  the  fluid  became  more  viscid,  bearing  a  strong  resemblance 


PARENCHYMATOUS    AND    INTRA-ARTICULAR   INJECTIONS.       271 

to  thin  mucus.  As  soon  as  this  stage  was  reached  the  effusion 
disappeared  speedily  and  permanently,  with  contemporaneous 
improvement  of  all  the  remaining  symptoms. 

Case  I.  Laboring  man,  aged  27  ;  has  inherited  a  rheumatic 
tendency ;  presented  himself  for  the  first  time  in  the  clinic,  April 
23,  1891;  general  health  unimpaired;  no  signs  or  symptoms 
of  pulmonary  tuberculosis.  Nine  months  ago  he  experienced 
pain  on  the  inner  side  of  the  right  knee-joint.  This  pain  was 
not  constant,  but  was  always  aggravated  by  active  exercise. 
Five  months  later  the  joint  became  swollen.  When  first 
examined,  the  joint  was  uniformly  swollen ;  movements  of  limb 
unimpaired  ;  upper  recess  of  synovial  sac  quite  prominent ;  fluc- 
tuation distinct ;  no  tender  points  over  condyles  of  femur  or 
head  of  tibia.  Primary  synovial  tuberculosis  with  hydrops  was 
the  diagnosis  made  at  the  time. 

The  joint  was  punctured  with  a  medium-sized  trocar  and 
about  four  ounces  of  a  turbid  synovial  fluid,  in  which  small 
flakes  of  lymph  were  suspended,  were  removed.  The  tapping 
was  followed  by  irrigation  of  the  joint  with  a  3-per-cent.  solu- 
tion of  boric  acid  until  the  fluid  injected  returned  perfectly 
clear.  One  ounce  of  iodoform  emulsion  was  injected.  The 
patient  was  advised  to  use  the  limb  moderately.  During  five 
weeks  the  same  procedure  was  repeated  three  times,  and  at 
each  successive  tapping  the  fluid  removed  was  less  in  quantity 
and  more  viscid.  When  the  patient  was  seen  again,  after  the 
fourth  injection,  the  joint  presented  a  normal  appearance ;  no 
effusion,  and  thickening  of  capsule  nearly  disappeared  ;  motion 
of  joint  nearly  normal.  As  the  patient  has  not  reported  since 
that  time,  it  is  fair  to  assume  that  he  has  completely  recovered. 

Case  IT.  Boy,  aged  8,  with  good  family  history,  entered 
the  Presbyterian  Hospital,  October  25,  1890,  suffering  with  hip 
disease.  The  disease  commenced  soon  after  an  injury,  which 
he  received  in  April,  1889.  Rest  in  bed  and  extension  by 
weight  and  pulley  was  the  treatment  employed.  Under  this 
treatment  the  pain  subsided,  but  the  swelling  and  tenderness 


272  TUBERCULOSIS   OF   THE    BONES    AND   JOINTS. 

remained  stationary.  During  the  month  of  May  three  injec- 
tions, from  two  drachms  to  half  an  ounce  of  the  emulsion  each 
time,  were  made  into  the  joint.  As  it  was  almost  certain  that 
the  head  and  neck  of  the  femur  were  the  primary  seat  of  the 
inflammation  in  this  case,  I  made  it  a  point  to  penetrate  the 
neck  of  the  femur  deeply  with  the  small  trocar  in  order  to  attack 
existing  osseous  foci  by  the  same  treatment.  The  emulsion  was 
first  thrown  into  the  substance  of  the  bone,  and,  later,  after 
withdrawing  the  cannula  as  far  as  the  surface  of  the  bone,  into 
the  joint. 

Several  days  after  the  last  injection  the  pain  became  sud- 
denly aggravated,  and  the  limb  shortened  in  spite  of  the  fact 
that  extension  was  kept  up  uninterruptedly ;  at  the  same  time 
the  limb  was  rotated  inward.  It  was  now  decided  to  resect  the 
joint.  The  operation  was  performed  June  7th.  The  great  tro- 
chanter,  with  the  muscles  attached  to  it,  was  cut  away  from  the 
shaft  at  the  base  of  the  neck  of  the  femur  with  a  chisel,  and, 
after  the  resection  of  the  joint,  was  replaced  and  fastened  to  the 
shaft  with  two  catgut  sutures.  Inspection  of  the  joint  now 
explained  the  symptoms  which  had  developed  recently  so 
suddenly. 

The  head  of  the  femur,  partially  destroyed,  had  slipped 
out  of  the  acetabulum  and  was  resting  upon  its  upper  brim.  A 
number  of  foci  were  found  in  the  neck  of  the  femur,  in  close 
proximity  to  the  head ;  the  joint  was  filled  with  granulations. 
No  signs  of  caseation.  The  granulations  were  firm  and  of  a 
bright-red  color,  and  I  have  no  doubt  had  this  accident  not 
occurred  the  parenchymatous  and  intra-articular  injections 
would  have  resulted  finally  in  a  cure.  The  neck  of  the  femur 
was  divided  at  its  junction  with  the  shaft  with  a  broad  chisel, 
and  removed  with  the  head.  The  capsule  was  extirpated,  and 
the  granulations  lining  the  acetabulum  scooped  out  with  a  sharp 
spoon.  Extension  in  abducted  position  was  continued  for  sev- 
eral weeks.  Primary  healing  of  the  wound  and  only  very 
slight  shortening,  with  leg  in  excellent  position. 


PARENCHYMATOUS    AND    INTRA-ARTICULAR    INJECTIONS.       273 

Case  III.  Farmer,  aged  53,  with  a  family  history  of  tuber- 
culosis, came  to  the  clinic  to  be  treated  for  tuberculosis  of  the 
wrist-joint  of  three  years'  standing.  General  health  fair;  muscles 
of  arm  atrophied ;  hand  slightly  flexed ;  arm  in  position  half 
way  between  pronation  and  supination.  Swelling  extended 
over  the  entire  wrist-joint,  and  presented  all  the  characteristic 
clinical  features  of  tuberculosis  of  this  joint.  During  the  course 
of  five  weeks  he  received  three  iodoform  injections,  the  quan- 
tity of  emulsion  used  each  time  being  sufficient  to  fully  dis- 
tend the  joint.  After  the  second  injection  the  swelling  and 
pain  began  to  subside,  and  four  weeks  later  the  joint  was 
practically  cured.  The  injections  were  always  made  below 
the  styloid  process  of  the  ulna  or  radius,  from  which  point  the 
trocar  was  made  to  traverse  the  entire  joint  from  side  to  side; 
the  injection  was  made  slowly  and  at  different  points  as  the 
cannula  was  withdrawn. 

Case  IV.  Girl,  aged  4,  with  good  family  history,  was 
brought  to  the  clinic  June  25th,  suffering  from  typical  tubercu- 
losis of  the  right  knee-joint.  The  disease  commenced  five 
weeks  before,  with  pain  and  lameness.  No  evidence  of  tuber- 
culosis in  any  other  organ ;  general  health  fair ;  knee-joint 
slightly  flexed,  but  only  moderately  swollen ;  no  effusion  in 
joint ;  capsule  thickened,  and  upper  recess  of  synovia!  sac 
evidently  the  seat  of  fungous  granulations.  Tenderness  over 
the  internal  condyle  of  the  femur  suggested  an  osseous  origin 
of  the  intra-articular  inflammation.  The  knee-joint  was  punc- 
tured, but  no  fluid  escaped.  In  order  to  ascertain  whether  the 
whole  knee-joint  could  be  medicated  by  intra-articular  injec- 
tion, boric-acid  solution  was  forced  into  it  from  a  fountain 
syringe  until  the  whole  joint  was  fully  distended ;  it  held 
about  two  ounces.  Half  an  ounce  of  iodoform  emulsion  was 
then  injected.  The  joint  became  more  swollen,  painful,  and 
tender  after  the  first  injection.  The  same  quantity  was  injected 
July  llth,  August  4th,  and  September  1st. 

At  the  present  time  the  position  of  the  limb  is  normal, 


274  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

motion  of  joint  fair,  thickening  of  capsule  greatly  diminished, 
and  less  tenderness  over  condyle. 

Case  V.  Girl,  aged  7,  was  admitted  into  the  Presbyterian 
Hospital,  March  24,  1891,  with  well-marked  advanced  tubercu- 
lar disease  of  hip-joint  of  two  years'  duration.  The  little  patient 
was  anaemic  and  emaciated.  Treatment  by  extension  and  paren- 
chymatous  and  intra-articular  injections  of  iodoform.  March 
24th,  April  28th,  and  May  28th,  I  ounce  of  iodoform  emulsion 
was  injected  into  the  neck  of  the  femur  and  hip-joint.  At  first 
the  patient  appeared  to  improve,  but  later  her  general  condition 
became  gradually  worse,  and  an  abscess  formed.  Resection  of 
the  hip-joint  was  made  July  16th.  September  9th  the  wound 
was  nearly  healed  and  the  general  condition  much  improved. 
The  resected  specimen  contained  a  number  of  caseous  foci,  which, 
at  least  in  part,  would  explain  the  failure  of  the  iodoform 
treatment. 

Case  VI.  Girl,  aged  7,  child  of  healthy  parents,  has  been 
suffering  for  two  months  from  chronic  inflammation  of  the  knee- 
joint.  Swelling  has  only  recently  appeared ;  limb  is  flexed  at 
an  angle  of  140  degrees ;  pain  aggravated  on  motion  of  the 
joint ;  no  fluctuation ;  tenderness  over  condyles  of  femur. 
Diagnosis:  Dry  fungous  synovitis  with  osseous  foci  in  con- 
dyles of  femur.  Half  an  ounce  of  iodoform  emulsion  was  in- 
jected into  the  joint  and  the  thickened  capsule  at  six  different 
times  from  March  18th  to  July  28th.  On  August  13th  the 
joint  was  carefully  examined,  and  the  appearances  were  such 
as  to  warrant  the  assumption  that  the  joint-lesion  was  cured. 
Pain  and  tenderness  on  moving  the  joint,  as  well  as  in  the 
condyles  of  the  femur,  had  disappeard.  The  limb  was  now 
easily  straightened,  while  the  patient  was  under  the  influence 
of  an  anesthetic,  and  immobilized  in  a  plaster-of-Paris  dressing. 
September  llth,  splint  removed;  position  of  limb  satisfactory; 
further  treatment,  consisting  of  massage,  passive  motion,  directed. 
Patient  can  'walk  without  the  aid  of  mechanical  support.  Pain, 
tenderness,  and  swelling  have  disappeared  completely. 


PARENCHYMATOUS    AND    INTRA-ARTICULAR   INJECTIONS.       275 

Case  VIL  Laborer,  aged  19;  very  good  family  history; 
two  years  ago  had  an  attack  of  peritonitis,  which  was  followed 
by  pain  and  swelling  of  one  of  the  wrist-joints.  An  abscess 
formed  and  was  opened  four  months  after  commencement  of 
joint  affection.  An  operation  was  made  a  year  ago.  When 
patient  was  presented  for  the  first  time  in  the  clinic  the  wrist- 
joint  was  very  much  swollen,  and  skin  over  it  for  some  distance 
cedematous ;  hand  flexed  and  forearm  pronated.  Fistulous 
openings  led  to  carious  bone ;  lower  end  of  radius  and  ulna 
enveloped ;  suppuration  slight ;  general  health  materially  im- 
paired, fividement  of  joint ;  wound  packed  with  iodoform 
gauze,  and  forearm,  as  far  as  base  of  fingers,  supported  by  a 
well-padded  anterior  splint.  The  sinuses  were  injected  with 
iodoform  emulsion  twice  a  week  for  two  months.  At  this  time 
the  wound  was  healed  completely,  and  the  patient  has  secured 
good  use  of  hand,  being  able  to  perform  manual  labor. 

Case  VIII.  Laborer,  aged  20 ;  family  history  good.  For 
a  number  of  weeks  patient  has  experienced  pain  in  left  knee- 
joint,  which  was  followed  by  swelling  four  weeks  ago,  since 
which  time  he  has  not  been  able  to  follow  his  occupation.  At 
the  time  treatment  was  commenced,  August  llth,  the  knee- 
joint  was  distended  with  fluid,  patella  raised  at  least  half  an 
inch  from  anterior  surface  of  condyles,  upper  recess  of  joint 
very  prominent,  and  conspicuous  bulging  on  each  side  of  patella. 
Diagnosis:  Primary  synovial  tuberculosis,  with  hydrops  of 
joint.  General  health  not  much  impaired.  Joint  was  tapped, 
and  ten  ounces  of  turbid  synovial  fluid,  mixed  with  shreds  of 
lymph,  removed.  The  joint  was  washed  out  repeatedly  with  a 
2-per-cent.  solution  of  boric  acid  until  the  fluid  returned  per- 
fectly clear,  when,  by  compression,  the  joint  was  completely 
emptied,  and  1  ounce  of  iodoform  emulsion  was  injected.  Next 
day  the  joint  was  swollen  as  much  as  before  the  tapping.  The 
patient  returned  August  25th,  and  stated  that  the  treatment 
had  proved  beneficial  to  him.  The  joint  was  again  tapped, 
but  only  half  the  quantity  of  fluid  removed  as  the  first  time. 


276  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

The  fluid  removed  contained  no  shreds,  and  was  clearer  and 
more  viscid  than  at  the  first  tapping.  The  second  injection 
produced  less  swelling  and  pain  than  the  first.  Two  weeks 
later  the  swelling  had  completely  disappeared,  thickening  of 
capsule  less,  and  the  patient  has  since  recovered  almost  perfect 
use  of  limb. 

Case  IX.  Brake  man,  aged  22;  admitted  into  Presbyterian 
Hospital  April  15,  1891  ;  tuberculosis  not  hereditary  in  his 
family.  About  five  years  ago  patient  experienced  a  sudden  pain 
in  left  knee,  which  was  followed  very  soon  by  swelling  and  local 
heat.  Since  that  time  the  knee  has  been  injured  on  three  dif- 
ferent occasions,  and  each  accident  was  always  followed  by 
aggravation  of  symptoms.  About  eighteen  months  ago  the 
pain  diminished,  but  the  patient  was  unable  to  walk  with- 
out the  aid  of  crutches.  The  patient  was  anaemic  and  consid- 
erably emaciated  ;  knee-joint  swollen  and  flexed  ;  no  effusion  in 
joint,  but  capsule  thickened  throughout;  circumscribed  point 
of  tenderness  over  inner  tuberosity  of  tibia.  Careful  search 
reveals  absence  of  tuberculosis  in  other  organs.  Diagnosis : 
Tubercular  osteo-arthritis  with  a  probable  focus  in  the  inner 
tuberosity  of  tibia.  Two  iodoform  injections  were  made  two 
weeks  apart,  but,  as  no  improvement  followed,  typical  resection 
of  knee-joint,  with  preservation  of  the  patella,  was  made  May 
3,  1891.  The  whole  synovial  membrane  was  found  converted 
into  a  granulation  mass,  and  capsule  of  joint  much  thickened. 
The  base  of  two  triangular  sequestra  in  the  head  of  the  tibia 
projected  into  the  joint.  The  articular  surface  of  the  two  frag- 
ments of  necrosed  bone  was  much  worn,  and  presented  a  pol- 
ished surface.  Primary  union  of  wound  and  bony  consolidation 
of  resected  ends  in  six  weeks.  The  inefficacy  of  iodoform 
treatment  was  explained  by  the  pathological  conditions  revealed 
at  the  operation.  Secondary  tubercular  synovitis  following  ex- 
tensive necrosis  from  occlusion  of  an  artery  by  a  tubercular 
thrombus  or  embolus  is  not  amenable  to  this  kind  of  treatment. 
If,  in  such  cases,  this  treatment  is  not  followed  by  improvement 


PARENCHYMATOUS    AND    INTRA-ARTICULAR   INJECTIONS.       277 

after  the  second  or  third  injection,  resection  is  indicated  and 
the  operation  should  not  be  postponed. 

It  is  my  opinion  that  even  in  such  cases  the  preliminary 
treatment  by  iodoform  injections  is  of  great  value,  as  it  brings 
the  infra-articular  structures  in  better  condition  for  successful 
operative  treatment.  I  regard  Ultra-articular  and  parenchy- 
matous  injections  of  iodoform  as  the  best  preparatory  treatment 
for  the  resection  of  tubercular  joints  in  which  this  treatment 
does  not  meet  the  pathological  indications. 

Case  X.  Boy,  aged  17,  with  a  tubercular  family  history, 
applied  for  treatment  in  the  college  clinic,  June  18,  1891. 
When  2  years  old,  symptoms  of  tubercular  spondylitis  in  the 
dorsal  region  first  developed.  In  spite  of  the  usual  treatment 
made  use  of  for  this  affection,  an  extensive  posterior  curvature 
formed.  The  patient,  although  17  years  of  age,  is  not  taller 
than  a  boy  of  7  or  8  years.  About  six  months  ago  a  swelling 
was  detected  in  the  left  iliac  region  which  rapidly  increased  in 
size.  The  patient  was  very  anaemic  and  greatly  emaciated. 
The  curve  involves  at  least  eight  or  nine  of  the  upper  dorsal 
vertebrae.  A  fluctuating  swelling,  reaching  from  Poupart's  liga- 
ment to  the  costal  arch  and  extending  to  near  the  median  line, 
was  found  on  the  left  side.  Diagnosis :  Tubercular  spondylitis 
of  upper  dorsal  vertebrae,  which  has  resulted  in  the  formation 
of  an  immense  lumbar  abscess,  which,  in  all  probability,  still 
communicates  with  the  primary  osseous  lesion.  The  abscess 
was  tapped  in  the  lumbar  region  immediately  below  the  last 
rib,  and  six  pints  of  characteristic  tubercular  pus  were  evacuated. 
The  abscess  was  washed  out  repeatedly  with  a  solution  of 
boric  acid  until  the  fluid  returned  perfectly  clear,  after  which 
an  ounce  of  iodoform  emulsion  was  injected. 

Between  June  18th  and  August  5th,  tapping,  irrigation, 
and  injection  was  repeated  four  times.  At  each  tapping  the 
quantity  of  fluid  removed  was  less,  so  that  the  last  time  not 
more  than  four  ounces  of  a  viscid,  opaque  fluid  were  removed. 
Since  then  there  has  been  no  re-accumulation  of  fluid,  and  the 


278  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

general  condition  of  the  patient  has  very  much  improved.  In 
its  results  the  treatment,  in  this  case,  has  proved  equally  satis- 
factory as  in  the  case  of  tubercular  spondylitis  described  above. 
These  two  cases  have  satisfied  me  that  the  iodoform  treatment 
will  prove  most  beneficial  in  the  treatment  of  chronic  abscesses 
which  develop  in  the  course  of  tubercular  spondylitis.  The 
value  of  this  method  of  tveatment  in  such  cases  cannot  be  over- 
estimated, inasmuch  as  little  can  be  expected  from  operative 
treatment  in  tuberculosis  of  the  vertebrae. 

It  is  only  by  keeping  such  cases  under  observation  for 
months  and  years  that  reliable  statistics  as  to  the  ultimate  results 
of  this  as  well  as  any  other  method  of  treatment  for  tubercular 
affection  of  bones  and  joints  can  be  obtained.  The  immediate 
effect  of  the  treatment  has  proven  highly  satisfactory  in  my 
hands,  and,  in  conclusion,  I  can  only  urge  its  more  general 
adoption  by  American  surgeons. 

CONCLUSIONS. 

1.  Parenchymatous  and   intra-articular  injections  of  safe 
antibacillary  substances  are  indicated  in  all  subcutaneous  tuber- 
cular lesions  of  bones  and  joints  accessible  to  this  treatment. 

2.  Of  all   substances  so  far  employed  in  this  method  of 
treatment,  iodoform  has  yielded  the  best  results. 

3.  The  curative  effect  of  iodoform  in  the  treatment  of  local 
tuberculosis  is  due  to  its  antibacillary  effect  and  its  stimulating 
action  on  the  healthy  tissue  adjacent  to  the  tubercular  product. 

4.  A  10-per-cent.  emulsion  in  glycerin  or  pure  olive-oil  is 
the  best  form  in  which  this  remedy  should  be  administered  sub- 
cutaneously. 

5.  The  ethereal  solution  should  never  be  employed,  as  it 
is  liable  to  cause  necrosis  of  the   tissues  overlying  the  abscess 
and  iodoform  intoxication. 

6.  Tubercular  abscesses  and  joints  containing  synovial  fluid 
or  tubercular  pus  should  always  be  washed  out  thoroughly  with  a 
3-  to  5-per-cent.  solution  of  boric  acid  before  the  injection  is  made. 


PARENCHYMATOUS   AND    INTR A- ARTICULAR   INJECTIONS.       279 

7.  Injections  should  be  made  at  intervals  of  one  or  two 
weeks,  and  their  use  persisted  in  until  the  indications  point  to 
the  cessation  of  tubercular  inflammation  and  the  substitution  for 
it  of  a  satisfactory  process  of  repair,  or  until  the  result  of  this 
treatment  has  shown  its  inefficacy  and  indications  present  them- 
selves of  the  necessity  of  resorting  to  operative  interference. 

8.  If  the    treatment    promise  to   be  successful,  symptoms 
pointing   to  improvement  manifest    themselves  not  later  than 
after  the  second  or  third  injection. 

9.  In  tubercular  empyema  of  joints  and  tubercular  abscesses 
gradual  diminution  of  the  contents  of  the  joint  or  abscess  at 
each  successive  tapping,  lessening  of  the  solid  contents  of  the 
fluid  and  increase  of  its  viscidity  are  the   conditions  which  in- 
dicate, unerringly,  that  the  injections  are  proving  useful  and 
that,  in  all  probability,  a  cure  will  result  from  their  further  use. 

10.  Moderate  use  of  limb  is  compatible  with  this  method  of 
treatment,  provided  the  disease  has  not  resulted  in  deformities 
which  would  be  aggravated  by  further  use  of  the  limb ;  in  such 
cases    correction    of  the    deformity   should  be  postponed  until 
the  primary  joint  affection  has  been  cured  by  the  injection. 

11.  Parenchymatous  and   intra-articular  medication  with 
antibacillary  remedies  has  yielded  Jhe  best  results  in  tubercular 
spondylitis,  attended  by  abscess  formation  and  tuberculosis  of 
the  knee-  and  wrist-  joints. 

12.  This  treatment  may  prove  successful  in  primary  osseous 
tuberculosis  followed  by  involvement  of  the  joint,  provided  the 
osseous  foci  are  small. 

If3.  Extensive  sequestration  of  articular  ends  with  secondary 
tubercular  synovitis  always  necessitates  resection,  but  prelimi- 
nary treatment  by  iodoform  injections  into  the  affected  joints 
constitutes  a  valuable  preparatory  treatment  to  the  operation 
and  adds  to  the  certainty  of  a  favorable  result. 

14.  In  open  tubercular  affections  of  joints,  incision,  scrap- 
ing, disinfection,  iodoformization,  iodoform-gauze  tampon,  sutur- 
ing, and  subsequent  injections  of  iodoform  emulsion,  as  advised 


280  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

by  Billroth,  yield  excellent  results,  and  should  be  employed  in 
all  cases  in  which  a  more  formidable  operation  can  be  avoided. 
15.  Balsam  of  Peru  ranks  next  to  iodoform  in  the  treatment 
of  tubercular  affections  of  bones  and  joints,  and  if  the  latter 
remedy,  for  any  reason,  cannot  be  employed,  or  has  failed  in 
effecting  the  desired  result,  it  should  be  given  a  fair  trial  if 
operative  treatment  is  riot  urgently  indicated. 


CHAPTER  XXV. 

OPERATIVE  TREATMENT. 

Arilirotomy,  or  incision  of  a  joint, — one  of  the  most 
efficient  surgical  procedures  in  the  treatment  of  suppurative 
arthritis, — has  only  a  very  limited  sphere  of  usefulness  as  a 
therapeutic  measure  in  the  treatment  of  tubercular  joints. 

Bouilly  ("  Absces  tuberculeaux  ;  intervention  chirurgicale." 
Gazette  des  Hopitaux,  No,  9,  1887)  prefers  the  iodoform- 
injection  treatment  in  patients  who  are  in  good  financial  circum- 
stances, where  time  is  no  object.  In  poor  patients,  to  expedite 
the  cure,  he  makes  a  free  incision,  scrapes  out  the  granulations 
lining  the  abscess-wall,  and  washes  the  cavity  with  a  solution 
of  chloride  of  zinc  and  packs  with  iodoform  gauze.  For  the 
last  few  years  Billroth  has  pursued,  in  proper  cases,  a  some- 
what similar  course.  He  renders  the  joint  as  accessible  as 
possible  by  incisions,  scrapes  out  the  granulations,  and,  after 
irrigation,  packs  with  iodoform  gauze.  This  method  of  treat- 
ment is  applicable  in  cases  in  which,  either  on  account  of 
unfavorable  local  or  general  conditions,  arthrectomy;  resection, 
or  amputation  are  contra-indicated,  and  after  subcutaneous 
iodoformization  has  been  given  a  fair  trial.  The  iodoform-gauze 
tampon  should  be  relied  upon,  in  securing  drainage,  in  prefer- 
ence to  tubular  drains.  This  method  of  treatment  may  also 
occasionally  be  indicated  and  prove  successful  in  the  treatment 
of  open  or  subcutaneous  abscesses  in  communication  with  a 
tubercular  joint.  In '  cases  of  this  kind  it  is  of  the  greatest 
importance,  after  the  infected  tissues  have  been  fully  exposed 
by  a  free  incision  to  direct  treatment,  to  take  special  pains  to 
procure  for  the  seat  of  disease  an  aseptic  condition  by  thorough 
antiseptic  measures  before  the  antitubercular  treatment  is 
instituted. 

Artlirectomy  (Volkmann),  erasion  of  joints  (Wright  and 
Collier),  synovectomy  (Oilier),  are  synonymous  terms  used  to 

(281) 


282  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

designate  a  modern  operation  on  tubercular  joints,  consisting  in 
the  removal  of  the  infected  soft  structure  of  the  joint  and  the 
scraping  out  of  bone-cavities,  if  such  are  present,  and  commu- 
nicate with  the  joint,  with  preservation  of  the  healthy  portions 
of  the  articular  extremities.  This  operation  was  first  devised 
and  practiced  by  the  surgeons  connected  with  the  Children's 
Hospital,  Pendlebury,  under  the  name  erasion  of  joints,  in 
January,  1887.  (Wright  and  Collier,  Ci  On  Erasion  or  Arthrec- 
tomy  of  the  Knee- Joint."  Annals  of  Surgery,  vol.  x,  p.  401.) 
The  operation  was  intended  as  a  substitute  for  typical  resection 
in  cases  where  the  articular  surfaces  were  intact,  or  only,  slightly 
involved,  so  that  the  diseased  part  can  be  removed  without  saw- 
ing through  the  articular  extremity  of  the  bone.  In  operating 
on  the  knee-joint,  Mr.  Wright  first  made  the  operation  through 
a  semilunar  incision  below  the  patella,  which  was  later  substi- 
tuted by  a  transpatellar  incision  through  the  soft  tissues  and 
the  centre  of  the  patella.  The  patella  was  always  sutured  after 
removal  of  the  intra-articular  disease.  Volkmann  published 
his  paper  on  "  Arthrectomia  Synovialis  "  in  1885  (Centralblatt 
/.  Chirurgie).  Through  the  influence  of  the  distinguished 
author  of  this  publication  the  operation  has  been  quite  gener- 
ally adopted  in  appropriate  cases,  and  has  yielded,  in  the  hands 
of  a  number  of  prominent  surgeons,  most  satisfactory  results. 
In  his  first  paper  on  this  subject,  Volkmann  entered  his  protest 
against  the  too  frequent  resort  to  excision  of  the  knee-joint, 
especially  in  children.  In  young  subjects  this  operation  has 
proved  often  very  unsatisfactory,  on  account  of  impairment 
of  bone  growth  and  subsequent  contraction,  and  he  is  inclined 
to  avoid  typical  resection,  wherever  practicable,  and  limit 
the  operation  to  a  thorough  removal  of  the  entire  capsule 
and  such  superficial  lesions  of  the  bone  that  can  be  reached 
from  the  articular  surfaces.  'He  again  called  attention  to  the 
fact  that  in  children,  in  the  osseous  form  of  tuberculosis  of  the 
knee-joint,  the  primary  foci  are  usually  very  minute  and  near 
the  articular  cartilage,  while  in  adults  the  disease  attacks  more 


OPERATIVE   TREATMENT.  283 

frequently  the  synovial  membrane  primarily.  He  is  of  the 
opinion  that  the  more  conservative  operation  of  arthrectomy  is 
urgently  indicated,  and  offers  the  best  prospects  of  a  favorable 
issue  and  a  good  functional  result  in  cases  of  so-called  fangcms 
articuli  of  the  old  authors,  in  which  the  capsule  of  the  joint, 
the  ligaments,  and  the  parasynovial  tissues  form  a  gelatinous 
mass  from  one-half  to  three-fourths  of  an  inch  in  thickness.  The 
preparatory  treatment  consists  in  the  correction  of  contractures, 
if  such  exist,  by  weight  and  pulley,  or  manual  extension  and 
permanent  fixation,  under  the  influence  of  an  anaesthetic.  If 
the  disease  is  complicated  by  tubercular  abscesses,  these  should 
be  incised,  scraped  out,  drained,  and  sutured;  Fistulous  tracts 
are  to  be  scraped  out  and  disinfected.  I  will  describe  here 
Volkmann's  method  of  performing  arthrectomy  of  the  knee- 
joint.  After  careful  preparation  of  the  patient,  the  operation 
is  commenced  by  opening  the  joint  by  a  transpatellar  incision, 
through  which  the  joint  can  be  examined  by  digital  exploration. 
If  this  examination  make  it  appear  that  it  is  necessary  to  extir- 
pate the  entire  capsule,  the  incision  is  extended  and  the  patella 
divided  transversely  with  the  saw.  If  the  bursa  underneath 
the  quadriceps  is  extensively  diseased,  the  incision  is  modified 
so  as  to  make  an  anterior  flap,  the  apex  of  which  corresponds 
with  the  uppermost  recess  of  the  bursa  and  the  base  a  little 
below  the  knee-joint.  Esmarch's  constrictor  is  only  used  in 
exceptional  cases,  as  the  loss  of  blood  from  parenchymatous 
oozing,  after  the  removal  of  the  constrictor,  is  more  than  would 
be  incurred  in  operating  without  elastic  constriction. 

The  bursa  is  first  removed  entire,  and  often  constitutes  a 
mass  of  considerable  size.  The  lower  extremity  of  the  femur  is 
thus  exposed  to  the  extent  of  three  to  four  inches  from  the 
articular  surface.  The  capsule  and  synovial  membrane  attached 
to  the  tibia,  as  well  as  the  semilunar  cartilages,  are  removed 
with  the  same  care.  The  rule  to  be  observed  in  these  cases  is 
to  remove  all  diseased  tissue  until  healthy  bone  and  muscular 
tissue  are  reached.  After  removal  of  the  soft  joint-structures  the 


284  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

articular  surfaces  must  be  carefully  inspected.  In  many  cases 
they  can  be  left  intact.  Osseous  foci  that  have  reached  the 
surface  should  be  removed  with  spoon  or  chisel,  and  it  may 
even  become  necessary  to  combine  the  arthrectomy  with  partial 
excision.  After  disinfection  of  the  fragments,  the  patella  is 
sutured  with  catgut  and  the  external  incision  closed,  with  the 
exception  of  the  two  lower  angles,  which  are  used  to  insert 
drains.  The  drains  are  placed  down  to,  but  not  between,  the 
articular  surfaces.  The  limb  is  dressed  in  a  straight  or  slightly 
flexed  position.  All  Volkmann  claims  for  this  operation  is 
safety  and  a  stiff  but  serviceable  limb.  He  places  great  stress 
on  continuing  the  mechanical  support  for  a  long  time,  in  order 
to  prevent  bending  of  the  joint  and  partial  dislocation  of  the 
articular  surfaces.  He  admits  that  in  this  operation  deep-seated 
osseous  foci  are  occasionally  overlooked,  but  claims  that  they 
are  not  always  detected  in  complete  excisions.  In  such  cases 
the  operation  removes  one  of  the  remote  dangers, — perforation 
of  the  foci  into  an  intact  joint, — and  the  osseous  lesions  can  be 
removed  later  by  a  secondary  operation.  This  operation  has 
had  its  supporters  and  its  opponents.  It  has  yielded,  on  the 
whole,  quite  satisfactory  results,  in  properly  selected  cases.  It 
is,  of  course,  applicable  only  in  the  treatment  of  tuberculosis 
of  such  joints  as  are  anatomically  so  located  that  they  can 
be  made  accessible  without  injuring  important  parts. 

Sendler  ("Beitrage  zur  Gelenk  Chirurgie."  Deutsche  Zeit- 
sclirift  /.  Chirurgie,  B.  xxvii,  p.  307)  reports  thirteen  cases  in 
which  diseased  joints  were  incised  fifteen  times;  in  four  the 
joint  was  only  incised  (arthrotomy) ;  in  the  remaining  cases 
complete  or  partial  arthrectomy  was  done  for  tubercular  lesions. 
With  the  exception  of  one  case,  recovery  was  effected  by  the 
operation  without  reaction.  In  five  cases  a  fair  degree  of 
mobility  of  the  joint  was  obtained,  although  in  two  of  them 
the  synovial  tuberculosis  was  caused  by  osseous  foci  of  consider- 
able size. 

In  two  cases  both  knee-joints  were  affected,  and  recovery 


OPERATIVE    TREATMENT. 


285 


with  a  fair  degree  of  motion  was  obtained.  He  urges  that  a 
movable  joint  should  be  aimed  at  in  all  cases  calling  for  simple 
puncture,  arthrotomy,  and  partial  arthrectomy  for  localized 
tubercular  processes.  The  same  intention  should  be  carried  out 
for  mild  diffuse  tuberculosis  without  implication  of  the  articular 
extremities,  and  in  the  milder  forms  of  synovial  tuberculosis 
complicated  by  small  osseous  foci,  and  likewise  in  cases  of 


FIG.  36.— PARTIAL  ARTHRECTOMY  OF  KNEE-JOINT.    (Medical  News.) 

tuberculosis  of  both  knee-joints;  at  least,  in  one  of  the  joints. 
Ankylosis  in  a  straight  position  should  be  aimed  at  in  all  grave 
forms  of  diffuse  synovial  tuberculosis,  and  in  all  severe  osseous 
forms.  If  the  conditions  of  the  joint  are  such  as  to  make  it 
expedient  to  obtain  a  movable  joint,  the  incision  should  be 
made  in  such  a  manner  that  the  motor  apparatus  of  the  joint 
will  not  be  disturbed ;  while  this  matter  does  not  enter  into 


286  TUBERCULOSIS   OF   THE    BONES   AND   JOINTS. 

consideration  if  ankylosis  is  intended,  in  which  case  the  incision 
is  made  in  such  a  manner  as  to  expose  the  joint  most  freely. 
Angerer  ("  Ueber  Gelenktuberculose."  Miinchener  Wochen- 
schrift,  No.  26,  1 888)  made,  in  two  years,  twenty-four  arthrecto- 
mies,  in  children  less  than  14  years  of  age,  for  tuberculosis.  In 
seventeen  of  these  cases  only  the  synovial  membrane  was 
extirpated,  while  in  the  remaining  number  a  thin  slice  of  the 
articular  cartilages  was  shaved  off  with  the  knife  at  the  same 
time,  because  the  granulations  had  penetrated  to  some  depth 
into  this  structure.  The  duration  of  the  disease  varied  from 
three  months  to  six  years.  The  youngest  patient  was  3J  and 
the  oldest  13 J  years  of  age.  In  all  cases  recovery  followed  in 
from  six  to  eight  weeks,  and  only  in  two  cases  did  local  recur- 
rence make  a  second  operation  necessary.  In  three  of  the 
patients  a  movable  joint  was  obtained ;  in  the  rest  ankylosis 
resulted,  or  at  least  motion  was  so  slight  as  to  be  of  no  service 
to  the  patient  in  the  use  of  the  limb.  Shortening  was  slight, 
but  in  a  number  of  cases  the  joint  became  somewhat  contracted. 

Albert  {Internationale  Klinische  Rundscliau,  April  14, 
1889)  regards  arthrectomy  as  a  useful  operation,  and  holds  that 
the  day  of  typical  resection  is  past ;  though  he  believes  that 
conservatism,  which  often  yields  a  better  ultimate  result  than 
operative  treatment,  is  not  sufficiently  appreciated  and  practiced 
at  the  present  time,  especially  in  the  treatment  of  children. 

Boeckel  {Revue  de  Cliirurgie,  February  26,  1888),  who  has 
performed  twelve  arthrectomies  of  the  knee,  all  successful, 
though  two  patients  died  later  of  pulmonary  phthisis,  favors  the 
operation  upon  adults,  as  the  mortality  is  less,  though  a  longer 
time  is  occupied  in  the  healing  process.  In  children  he  prefers 
excision.  Lucas-Cham pionniere,  with  the  majority  of  French 
surgeons,  regards  resection  as  the  better  operation,  being  more 
thorough,  no  more  dangerous,  and  more  quickly  recovered  from. 
Tiling  ("  Vorschlage  zur  Technik  der  Arthrektomie  resp.  Resek- 
tion,"  etc.  St.  Petersburger  Med.  WocJienschrift,  Nos.  33  and 
34,  1887),  with  a  view  to  preserve  more  of  the  capsule  and 


OPERATIVE    TREATMENT.  287 

muscular  attachments  of  the  joints  in  arthrectomy  and  resec- 
tion, has  proposed  for  the  different  joints  temporary  resection  of 
the  portions  of  the  articular  extremities  to  which  important 
muscles  and  other  joint-structures  are  attached,  thus  procuring 
free  access  to  the  joint  for  the  removal  of  diseased  tissue ;  and 
these  fragments  are  then  replaced  and  fastened  with  bone  or 
ivory  nails  after  the  partial  resection  or  arthrectomy  is  com- 
pleted. In  the  knee-joint  the  spine  of  the  tibia — the  part  to 
which  the  patellar  tendon  is  attached — is  thus  temporarily 
detached  and,  later,  replaced ;  in  the  hip  the  trochanter  major 
is  dealt  with  in  a  similar  manner,  and  in  resection  of  the  elbow 
the  olecranon  is  temporarily  resected,  and  in  the  ankle-joint  the 
malleoli  are  detached  before  and  replaced  and  fastened  after 
completion  of  the  arthrectomy.  I  have  followed  Tiling's  sug- 
gestion in  a  number  of  hip-  and  elbow-  joint  resections,  and 
have  been  well  satisfied  with  the  operations  and  their  results. 
The  joint  that  is  best  adapted  for  arthrectomy  is  the  knee-joint, 
and  more  than  two- thirds  of  all  the  operations  performed  up  to 
date  were  made  on  this  joint.  About  two  years  ago  Schede  made  a 
number  of  arthrectomies  on  the  hip-joint  through  a  large  curved 
posterior  incision,  which  enabled  him  to  dislocate  the  head  of 
the  femur  upon  the  dorsum  ilii,  which,  after  the  extirpation  of 
the  capsule,  he  replaced.  It  is  not  probable  that  this  operation 
will  ever  become  popular,  as  the  large  resection  wound,  which 
it  is  necessary  to  make  to  expose  the  joint  freely,  is  a  serious 
objection  in  many  of  the  cases  requiring  arthrectomy.  I  will 
describe  here  my  plan  of  extirpating  the  soft  structures  of  a 
tubercular  knee-joint.  This  operation  is  applicable  in  all  cases 
of  primary  synovial  tuberculosis,  in  preference  to  resection,  as 
by  it  the  diseased  tissue  can  be  effectually  removed  without 
unnecessary  loss  of  healthy  tissues  that  are  necessarily  sacrificed 
by  the  latter  operation.  The  immediate  and  ultimate  success 
of  an  operation  for  tubercular  joint  affections  depends  largely 
upon  the  thoroughness  with  which  the  operation  is  done  and 
the  absence  of  suppuration. 


288  TUBERCULOSIS    OF   THE    BONES    AND   JOINTS. 

Arthrectomy  should  be  done  before  fistulous  openings  have 
formed,  and  the  joint  must  be  opened  by  an  incision  that  will 
expose  every  nook  and  corner  of  the  capsule.  Of  the  many 
incisions  that  have  been  devised  for  opening  the  knee-joint, 
Volkmann's  incision — the  one  I  shall  here  describe — offers  the 
greatest  advantages  and  is  open  to  the  least  objection.  The 
old-fashioned  horseshoe  incision,  with  the  convexity  directed 
downward,  makes  it  very  difficult  to  suture  the  wound,  and 
leaves  a  scar  where  it  is  most  exposed  to  injury.  The  trans- 
verse incision,  carried  directly  across  the  knee-joint,  if  the 
patella  is  divided  at  the  same  time,  leaves,  subsequently,  the 
superficial  and  deep  parts  of  the  wound  directly  opposite;  if 
the  patella  is  preserved  the  scar  of  the  external  incision  falls 
upon  the  most  prominent  part  of  the  patella,  which  is  again_a 
great  disadvantage.  The  incision  which,  for  several  years,  I 
have  always  selected  in  opening  the  knee-joint,  in  performing 
arthrectomy  or  excision,  is  a  curved  incision,  but  the  convexity 
of  the  curve  is  directed  upward.  It  is  carried  from  the  most 
dependent  portion  of  the  knee-joint,  at  a  point  corresponding  to 
the  most  prominent  part  of  the  internal  condyle  of  the  femur, 
in  a  gentle  curve,  to  an  inch  above  the  upper  border  of  the 
patella,  and  from  here,  downward  and  outward,  to  a  point  oppo- 
site where  it  was  commenced.  The  short,  semilunar,  cutaneous 
flap  is  now  detached  and  turned  downward  to  a  point  corre- 
sponding with  the  insertion  of  the  tendon  of  the  patella.  After 
this  an  incision  is  carried  directly  across  the  joint,  dividing  the 
lateral  ligaments  and  crossing  the  patella  transversely  at  its 
centre.  The  patella,  at  this  step  of  the  operation,  is  divided 
with  a  saw.  The  upper  portion  of  the  synovial  sac  is  freely 
opened  by  making  an  incision  on  each  side  of  the  upper  half 
of  the  patella,  which  is  carried  as  far  as  the  upper  recess  of  the 
synovial  sac.  The  rectangular  flap,  composed  of  the  upper 
fragment  of  the  patella,  with  its  muscular  attachments,  is  re- 
flected, which  exposes  every  portion  of  the  upper  part  of  the 
synovial  recess.  A  somewhat  similar  flap  is  made  of  the  lower 


OPERATIVE    TREATMENT.  289 

half  of  the  patella,  and  its  tendon  reflected  in  a  downward 
direction,  by  which  the  tissues  underneath  that  portion  of  the 
patella  and  its  ligaments  are  fully  exposed.  With  the  knee- 
joint  thus  exposed,  it  is  not  difficult  to  extirpate,  with  the  help 
of  a  catch-forceps,  a  sharp  scalpel,  and  a  pair  of  curved  scissors, 
the  entire  capsule.  The  part  of  the  capsule  that  will  be  found 
most  difficult  to  remove  is  that  portion  which  covers  the  pop- 
liteal vessels  and  dips  down  behind  the  condyles  of  the  femur 
and  behind  the  tuberosities  of  the  tibia.  During  this  part  of 
the  operation  the  leg  must  be  forcibly  flexed  over  a  small 
cushion,  or  the  fist  of  an-  assistant,  in  the  popliteal  space. 

Arthrectomy  is  always  a  tedious  operation,  as  it  is  abso- 
lutely necessary  to  remove  all  of  the  infected  tissues  in  order  to 
secure  permanent  success.  If  the  patella  is  not  diseased  it 
should  never  be  removed.  After  the  capsule  has  been  extir- 
pated the  patella  is  united  by  two  chromicized  catgut  sutures. 
I  have  never  failed  in  obtaining  bony  union  in  four  to  six  weeks 
after  this  method  of  coaptation.  After  extirpation  of  the  capsule, 
and  before  the  elastic  constrictor  is  removed,  the  whole  surface 
should  be  once  more  irrigated  with  a  hot  solution  of  corrosive 
sublimate  (1  to  1000)  or  iodine- water,  after  which  it  is  rubbed 
off  with  iodoform  gauze  in  order  to  remove  any  detached  frag- 
ments of  tubercular  tissue  that  have  not  been  washed  away. 
The  whole  surface  is  now  freely  sprinkled  with  impalpable  iodo- 
form, which  is  rubbed  into  the  surface.  Before  the  constrictor 
is  removed  the  wound  is  packed  with  aseptic  gauze,  the  flaps 
are  laid  over  it,  and  manual  compression  made  for  five  or  ten 
minutes  after  the  removal  of  the  constrictor  with  the  limb  in  an 
elevated  position.  This  simple  procedure  serves  an  admirable 
purpose  in  controlling  capillary  haemorrhage,  and  reduces  the 
necessity  of  recourse  to  ligature  to  a  minimum.  After  all  the 
bleeding  has  been  arrested  the  patella  is  sutured,  and  the  deep 
parts  of  the  wound  are  united  by  buried  sutures  of  catgut. 
Tubular  drainage  can  usually  be  dispensed  with,  as  a  capillary 
drain  composed  of  a  few  threads  of  catgut  will  answer  an  excel- 


19 


290  TUBERCULOSIS   OF   THE   BONES   AND    JOINTS. 

lent  purpose,  and  will  not,  like  the  tubular  rubber  drain,  neces- 
sitate an  early  change  of  dressing.  The  external  incision  is 
closed  with  silk  sutures,  the  line  of  suturing  being  out  of  the 
way  of  the  patella,  the  parts  united  with  the  buried  sutures  be- 
ing covered  throughout  by  the  external  flap.  A  careful  hsemo- 
stasis  and  rigid  antiseptic  precautions  will  make  it  unnecessary 
to  change  the  dressing  earlier  than  the  end  of  the  second  week, 
and  on  this  account  I  prefer  to  immobilize  the  limb  in  a  plaster- 
of- Paris  splint  applied  over  a  copious  antiseptic  dressing.  The 
limb  must  be  kept  in  an  elevated  position  for  at  least  six  hours 
after  the  operation,  so  as  to  diminish  the  amount  of  parenchy- 
matous  hemorrhage.  If  all  the  infected  tissue  has  been  re- 
moved and  the  wound  remains  in  an  aseptic  condition,  the 
external  wound  will  be  found  closed  in  the  course  of  two  or 
three  weeks.  A  fair  restoration  of  function  with  partial  mobil- 
ity of  the  joint  can  be  expected  in  favorable  cases.  Passive 
motion  must  be  delayed  until  the  patella  has  firmly  united, 
which  will  require  from  three  to  four  weeks  in  children  and 
nearly  twice  this  length  of  time  in  adults.  After  the  patella  has 
united  and  the  external  wound  is  completely  healed,  recovery 
is  hastened  by  passive  motion,  massage,  and  the  use  of  the 
faradic  current.  Arthrectomy  has  a  promising  future  in  the 
treatment  of  primary  synovial  tuberculosis  of  the  knee-  and 
elbow-  joints,  but  for  well-known  anatomico-pathological  rea- 
sons it  is  not  equally  applicable  in  the  treatment  of  similar 
affections  of  any  other  of  the  larger  joints.  It  is  possible  that 
the  present  operative  technique  will  be  modified  and  sufficiently 
perfected  in  the  future  so  as  to  bring  the  hip-,  ankle-,  wrist-,  and 
shoulder-  joints  within  the  limits  of  its  present  utility  in  the 
treatment  of  surface  tuberculosis  of  the  other  large  joints.  In 
several  cases  of  tuberculosis  of  the  elbow-joint,  I  obtained  an 
excellent  result  from  arthrectomy  combined  with  temporary 
resection  of  the  olecranon  process.  This  process  was  divided 
obliquely  with  a  saw  at  its  junction  with  the  shaft  of  the  ulna, 
and,  after  the  extirpation  of  all  of  the  infected  soft  tissues  of  the 


OPERATIVE   TREATMENT.  291 

joint,  the  process  was  fastened  in  its  proper  place, — in  one  case 
with  small,  aseptic,  ivory  nails ;  in  the  others  with  catgut  sutures. 
In  all  of  these  cases  the  functional  result  was  excellent,  a  strong 
arm  and  a  fair  range  of  motion  in  the  joint. 


CHAPTER  XXVI. 

RESECTION. 

THE  operative  removal  of  portions  or  the  entire  articular 
extremities  for  injury  or  disease  is  called  resection.  Until  quite 
recently  this  operation  was  made  by  removing  both  articular 
extremities,  which  is  now  called  a  complete  or  typical  resection 
to  distinguish  it  from  a  more  modern  and  conservative  opera- 
tion which  aims  only  at  the  removal  of  injured  or  diseased 
portions  of  the  articular  surfaces,  and  is  known  as  partial  or 
atypical  resection.  Both  of  these  operations  have  their  distinct 
and  specific  indications  in  the  treatment  of  tubercular  affections 
of  joints,  according  to  the  primary  location  and  extent  of 'the 
disease. 

History. — The  operation  of  resection  of  joints  is  mentioned 
by  Hippocrates  in  the  treatment  of  irreducible  dislocations,  and 
Celsus  speaks  of  it  in  connection  with  compound  dislocations. 
Paulus  Agineta  was  the  first  to  recommend  excision  of  the 
articular  ends  of  bones  in  certain  grave  cases  of  joint  disease. 
This  indication  for  resection,  laid  down  by  Agineta,  was  revived 
by  Ambrose  Pare. 

The  names  of  Pare,  Broucher,  and  Thomas  are  intimately 
associated  with  the  history  of  surgery  pertaining  to  preservation 
of  life  and  limb  by  resection  of  injured  and  diseased  joints. 
White's  famous  operation  was  made  in  1768.  Bent,  Orred,  but 
especially  Park,  in  England;  Lentin  and  Gorke,  in  Germany; 
the  Moreaus  and  Percy,  in  France,  were  enthusiastic  followers 
of  White,  and  extended  the  operation  to  other  joints.  The 
application  of  this  method  of  treatment  to  different  joints  was 
strongly  urged  and  diligently  carried  out  by  the  two  Moreaus 
and  Roux.  The  most  distinguished  and  influential  surgeons  in 
France,  like  Dupuytren  and  Delpech,  occasionally  made  a  re- 
section. Baron  Larrey,  Percy,  Champion,  and  several  others 
resorted  to  it  even  in  their  military  practice,  but  the  general 
(292) 


RESECTION.  293 

mass  of  surgeons  took  no  interest  in  this  subject.  Later,  Chas- 
siagnac,  Maisonneuve,  Nelaton,  and  Malgaigne  introduced  new 
methods  of  operating,  and  in  other  ways  rendered  valuable 
service  in  bringing,  resection  to  the  favorable  notice  of  the  pro- 
fession. In  England,  Crampton  and  Syme,  in  1827  and  1831, 
revived  the  almost  forgotten  and  utterly  ignored  operation,  but 
it  did  not  gain  a  firm  foothold  until  again  established  through 
the  clear  teachings  and  firm  example  of  Ferguson  (1850).  In 
1831  Mr.  Syme  ("  Treatise  on  the  Excision  of  Diseased  Joints," 
1831)  called  attention  to  the  then  almost  obsolete  operation  in 
the  following  language: — 

"  Though  amputation  is  a  measure  very  disagreeable  both 
to  the  patient  and  to  the  surgeon,  it  has,  hitherto,  with  hardly 
any  exception,  been  regarded  as  the  only  safe  and  efficient  means 
for  removing  diseased  joints  which  did  not  admit  of  recovery." 
The  idea  of  cutting  out  merely  the  morbid  parts,  and  leaving 
the  sound  portions  of  the  limb,  seems  to  have  hardly  ever 
occurred,  or  to  have  been  met  by  so  many  objections  that  it  was 
almost  instantly  abandoned.  From  1830  to  1850,  the  operation 
was  performed  almost  exclusively  in  Germany.  Among  the 
early  advocates  of  this  operation  in  that  country,  besides  those 
enumerated  above,  should  be  mentioned  Palm  and  Grafe,  fol- 
lowed later  by  Jager,  Textor,  Fricke,  Heine,  J.  F.  Heyfelder, 
Bied,  Langenbeck,  A.  Meyer,  Stromeyer,  and  Esmarch.  As  late 
as  1839,  Hichter  ("Die  Orgatiischen  Knochen-Krankheiten," 
p.  51.  Berlin,  1839)  placed  a  very  low  estimate  on  the  value 
of  resection,  as  is  apparent  from  the  following  quotation :  "  Die 
Resection  der  Knochen  ist  mehr  als  chirurgisches  Knuststiick, 
als  eine  Heilung  bringende  Operation  zu  betrachten,  und,  teils 
des  verletzenden  Eingriffs,  teils  der  Grossen  Unsicherheit  des 
Erfolges  wegen,  insofern  selbst  beim  Glucklichsten  Ausgange 
dem  Kranken  immer  nur  ein  verstummeltes  und  unbrauchbares 
Glied  erhalten  wird,  zu  venneiden."  The  valuable  services 
rendered  by  men  of  more  recent  date,  like  Langenbeck,  Volk- 
mann,  Konig,  Kocher,  and  Billroth,  in  the  development  of  this 


294  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

department  of  surgery,  are  too  well  known  to  require  more  than 
simply  mentioning  their  names.  In  Holland,  Mulder  estab- 
lished resection  of  joints  as  a  legitimate  surgical  procedure.  In 
Italy  it  was  introduced  by  Regnoli  and  Sarghi.  In  our  own 
country  it  gained  a  firm  foothold  through  the  labors  of  Mott, 
Rhea,  Barton,  Say  re,  and  Bauer. 

Indications  for  Operation. — Resection  of  a  tubercular  joint 
is  indicated  when  a  primary  osseous  focus  or  foci  cannot  be 
reached  by  an  extra-articular  operation,  when  the  joint  has  become 
invaded  secondarily,  and  when  a  primary  sy  no  vial  tuberculosis 
has  extended  to  the  articular  surfaces  of  the  bones,  and  the  dis- 
ease has  proved  refractory  to  less  heroic  measures.  A  great  dis- 
crepancy of  opinion  still  prevails  among  surgeons,  even  at  the 
present  time,  both  in  reference  to  the  utility  of  this  operation  and 
the  proper  time  when  it  should  be  performed.  Not  a  few  condemn 
operative  treatment  altogether,  and  pursue  an  entirely  conserva- 
tive plan  of  treatment.  Others  admit  that  resection  is  a  justifiable 
operation  and  assign  to  it  a  limited  application  in  their  prac- 
tice, but  restrict  it  as  a  dernier  ressort,  in  cases  where  the  dis- 
ease has  far  advanced  or  where,  in  consequence  of  it,  the  gen- 
eral condition  of  the  patient  has  been  seriously  affected.  Thus, 
according  to  Selenkow  ("  Zur  operativen  Behandlung  der  Tuber- 
culose."  St.  Petersburger  Med.  Wochenschrift,  No.  19,  1884), 
Pirogoff  came  to  the  conclusion  that  resection  alone  seldom  ac- 
complishes complete  removal  of  all  tubercular  material,  and  that, 
consequently,  a  speedy  return  of  the  disease  would  follow  unless 
other  precautions  were  resorted  to.  A  third  class  of  surgeons 
regard  resection,  or  one  of  its  modern  substitutes — arthrectomy 
— as  the  most  efficient  means  in  removing  the  local  disease  and  in 
preventing  general  infection,  and  consequently  plead  in  favor  of 
early  radical  interference.  The  opponents  of  the  operation  claim 
that  better  local  and  general  results  are  obtained  without  it,  and 
that  the  operation  not  infrequently  is  the  direct  cause  of  local  and 
general  dissemination  of  the  disease.  There  can  be  no  doubt  that 
the  antiseptic  treatment  of  wounds  and  improved  methods  of 


RESECTION.  295 

Operating  which  have  recently  been  devised  for  different  joints 
have  not  only  greatly  diminished  the  great  risks  of  trumatic  in- 
fection, but  have  at  the  same  time  influenced  surgeons  in  making 
the  operation  earlier  and  more  thorough,  and  thus  improve  the 
local  results  and  greatly  reduce  the  danger  incident  to  traumatic 
infection.  It  is  not  possible  to  lay  down  cast-iron  rules  in 
pointing  out  the  indications  for  resection,  as  both  the  local  and 
general  conditions  must  be  carefully  considered  in  each  case  be- 
fore deciding  upon  the  propriety  or  justifiability  of  an  operation. 
Unless  the  general  condition  of  the  patient  furnishes  a  contra- 
indication, it  may  be  stated  as  a  rule  that,  in  all  recent  cases  of 
primary  synovial  tuberculosis,  treatment  should  be  commenced 
with  intra-articular  and  parenchymatous  injections  of  iodoform, 
and,  if  necessary,  by  rest  and  immobilization  of  limb,  and  this 
treatment  should  be  continued  for  some  length  of  time  before  an 
operation  is  decided  upon.  If  no  improvement  follow  this 
treatment,  or  if,  in  spite  of  it,  the  symptoms  become  aggravated, 
the  joint  should  be  opened,  and  the  conditions  then  revealed 
will  point  out  whether  an  arthrectomy  or  a  partial  or  complete 
resection  should  be  made.  Extensive  deformity  of  the  joint, 
regardless  of  the  extent  of  the  disease,  indicates  a  resection,  as 
this  operation  alone  can  restore  partly  or  completely  the  func- 
tion of  the  limb.  Incipient  pulmonary  tuberculosis,  developing 
in  the  course  of  a  tubercular  disease  of  a  joint,  has  often  been 
arrested  by  a  prompt  operative  removal  of  the  local  disease  in 
the  joint.  Age  furnishes  no  centra-indication  to  the  operation, 
although  the  immediate  and  remote  results  are  much  better  in 
children  than  adults.  Konig  showed  long  ago  that  resection  of 
tubercular  joints  in  the  aged  is  often  followed  by  the  most  happy 
results. 

Schliiter  ("  Knieresection  im  hoheren  Alter  wegen  Tuber- 
culose."  DeutscJie  Zeitrsclirift  f.  Cliirnrgie,  B.  xxx,  p.  285) 
reports  100  cases  of  tuberculosis  of  the  knee-joint  occurring  in 
persons  who  had  passed  the  age  of  20,  in  which  resection  was 
performed.  The  operation  adopted  was  usually  that  of  Yolk- 


296  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

mann  ;  but  sometimes  the  joint  was  exposed  by  a  curved  incision 
below  the  patella.  Healing,  as  a  rule,  occurred  without  com- 
plications, the  average  period  being  two  months  ;  in  some  of  the 
cases  recovery  was  retarded  by  suppuration  and  recurrence  of 
the  disease.  The  results  in  these  cases  show  complete  recovery 
in  44,  3  not  improved,  11  underwent  amputation,  32  died,  and 
10  were  lost  sight  of.  In  the  44  cases  where  a  cure  was  effected, 
recovery  was  still  permanent  ten  years  after  the  operation.  The 
same  author  has  also  collected  187  cases  of  resection  of  the  knee 
for  tuberculosis  in  adults,  with  30  per  cent,  of  cures.  His  con- 
clusion, in  reference  to  resection  in  persons  advanced  in  life,  is 
that  the  operation  gives  a  useful  limb  in  64  per  cent  within 
half  a  year  after  the  operation.  Tubercular  joints  with  open, 
suppurating,  fistulous  tracts,  in  the  majority  of  cases,  should 
be  subjected  to  resection.  The  complete  operative  removal  of 
all  the  infected  tissues  in  suppurating  tubercular  joints  will  often 
arrest  incipient  amyloid  degeneration  of  internal  organs  ;  but  if 
this  secondary  disease  is  far  advanced  the  operation  will  only 
hasten  a  fatal  termination,  and  should  not  be  attempted.  It 
should,  finally,  be  said  that  operations  can  often  be  performed 
successfully,  and  will  lead  to  a  favorable  termination,  in  an  hos- 
pital provided  with  all  modern  means  of  successful  wound 
treatment,  while  similar  operations  on  the  same  patients  in 
private  practice  would  almost  surely  prove  failures.  It  can, 
therefore,  be  regarded,  as  a  rule,  that  resection  is  more  fre- 
quently  indicated  in  hospital  than  in  private  practice.  A  great 
many  surgeons  have  opposed  resection  in  children  on  account 
of  one  of  the  well-known  evil  results  of  the  operation,  viz.: — 
SJiortenincj  of  the  Limb. — Mr.  Syme  appears  to  have  been 
the  first  surgeon  who  called  attention  to  the  occurrence  of  short- 
ening after  removing  the  epiphysial  line  in  excision  of  joints, 
for  he  found  that  the  limb  of  a  little  patient,  the  knee-joint  of 
which  he  excised  in  1830,  after  the  lapse  of  time,  failed  to  grow 
at  a  rate  corresponding  to  that  of  its  fellow  ("Contributions  to 
the  Pathology  and  Practice  of  Surgery,"  p.  225).  Mr.  Butcher 


RESECTION.  297 

("  Memoirs  on  Excision  of  the  Knee-Joint,"  1856  and  1858) 
and  other  surgeons  who  have  written  on  the  subject  of  excisions 
seem  inclined  to  disbelieve  the  fact  that  a  cessation  of  growth  is 
caused  in  a  limb  from  which  the  epiphysial  cartilages  have  been 
removed  in  childhood. 

Mr.  Page,  Dr.  Keith,  and  Mr.  Jones  also  maintained  the 
opinion  that  the  removal  of  the  epiphysial  cartilages  does  not 
interfere  with  the  normal  growth  of  the  limb.  Mr.  Price  (ibid., 
p.  151),  after  giving  the  result  of  his  own  clinical  observations 
in  reference  to  this  point,  continues:  "I  could  quote  various 
other  cases,  illustrating  the  want  of  adequate  growth  in  a  limb 
after  its  knee-joint  has  been  excised  at  an  early  period  of  life, 
but  I  consider  the  above  sufficient  for  our  purpose." 

Oilier  (;;  Sur  la  resection  de  la  hanche  dans  les  coxalgies 
suppurees."  Lyon  Medical,  No.  18,  1881.  Ibid.,  Revue  de 
Chiruryie,  1881,  pp.  177,  369,  548)  studied,  experimentally 
and  clinically,  the  causes  of  shortening  after  resection  of  the 
hip-joint.  He  maintains  that  the  shortening  follows  in  conse- 
quence of  removal  of  the  upper  centre  of  growth,  the  epiphysial 
cartilage.  He  asserts  that  the  femur  grows  in  length  equally 
at  both  extremities  of  the  bone  in  children  under  4  years  of  age, 
but  that  after  this  time  the  growth  of  the  length  of  the  bone  at 
the  lower  epiphysis  is  double  that  of  the  upper  end ;  so  that, 
while  the  bone  grows  two  centimetres  in  length  at  the  lower 
end,  only  one  centimetre  is  added  to  the  upper.  He  expects 
ultimately  nine  centimetres  of  shortening  if  the  upper  epiphysis, 
with  cartilage,  is  removed  in  a  child  4  years  of  age  ;  deviation 
of  the  pelvis  compensates  for  the  shortening,  even  if  this  amounts 
to  from  seven  to  eight  centimetres. 

Julius  Wolff  ("  Ueber  Ellenbogen  und  Hiift  gelenk-resec- 
tion."  VerJi.  d.  Deutsclien  Geselhchaft  f.  Chirurgie,  1882) 
made  a  complete  resection  of  the  elbow-joint  in  a  child  3  years 
of  age,  and  had  an  opportunity  to  make  a  careful  examination 
nine  years  later.  The  resection  involved  the  removal  of  the 
epiphysial  cartilage  of  all  three  bones  entering  into  the  forma- 


298  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

tion  of  the  elbow-joint.  On  accurate  measurements  it  was  found 
that  the  resected  humerus  was  a  little  longer  than  the  opposite 
one,  and  the  ulna  was  two  centimetres  shorter,  while  the  radius 
showed  only  five  millimetres  shortening.  In  a  case  of  subtrochan- 
teric  resection  of  the  femur,  in  a  boy  12  years  of  age,  he  found, 
at  the  end  of  nine  and  one-half  years,  that  the  shortening 
amounted  only  to  two  and  one-half  centimetres,  which  would 
indicate  that  the  growth  of  the  resected  bone  was  not  impaired 
by  the  removal  of  one  of  its  epiphysial  cartilages.  In  two  cases 
of  resection  of  the  knee-joint  in  children,  Albrecht  ("  Ueber  den 
Ausgang  der  fungosen  Gelenk  entziindungen  und  die  Bedeutung 
der  Gelenkresection  bei  solchen."  Deutsche  Zeitsclirift  f. 
Chirurgie,  B.  xix)  found,  after  seven  and  eight  years,  twenty 
centimetres  of  shortening. 

Tiling  ("  Vorschlage  zur  Technik  der  Arthrectomie  resp. 
Resection  an  Schulter,  Ellenbogen,  Hiifte,  Knie  und  Fussge- 
lenk."  St.  Petersburger  Med.  Wochenschrift,  Nos.  33,  34,  1887) 
reminds  us  that  the  modern  methods  of  resecting  joints  have, 
for  their  main  objects,  to  render  all  the  joint-structures  easily 
accessible  to  direct  treatment  and  the  preservation,  whenever 
possible,  of  intact  parts  of  joints  which  are  important  in  secur- 
ing a  good  functional  result.  He  describes  modifications  of 
operations  on  nearly  every  one  of  the  large  joints,  the  main 
features  of  the  new  operation  consisting  in  temporary  resections 
of  parts  of  the  joint  which  serve  as  points  of  attachment  of 
important  ligaments  and  muscles.  After  the  completion  of  the 
resection,  these  partially  detached  pieces  of  bone  are  fastened 
in  their  respective  places  by  catgut  sutures  or  aseptic,  absorbable 
nails.  In  the  knee-joint,  for  instance,  the  tibial  insertion  of  the 
tendon  of  the  patella  is  preserved  by  the  temporary  resection  of  a 
triangular  piece  of  the  spine  of  the  tibia.  In  the  hip-joint,  it  is 
suggested  to  detach  the  trochanter  major,  with  all  its  important 
muscular  insertions  which  afford  free  access  to  the  joint,  when, 
after  the  completion  of  the  resection,  the  apophysis  is  fixed  in  its 
place  with  ivory  nails.  In  the  same  manner  the  malleoli  are 


RESECTION.  299 

dealt  with  in  operations  on  the  ankle-joint  and  the  epicondyles 
of  the  humerus  and  olecranon  process  of  resection  of  the  elbow- 
joint.  There  can  be  no  doubt  that  in  young  children  the  re- 
moval of  one  or  more  of  the  epiphysial  extremities  of  the  long 
bones  gives  rise  to  more  or  less  progressive  shortening  of  the 
limb  in  nearly  all  cases  in  which  the  bone-producing  structures 
are  destroyed  by  the  disease  or  removed  by  the  operation.  As 
the  shortening,  under  such  circumstances,  has  often  amounted 
to  several  inches,  and  that  from  this  source  alone  the  patient 
lost  the  use  of  the  limb,  it  is  not  surprising  that  surgeons  are 
aiming  more  and  more  to  limit  the  operation  to  the  removal  of 
the  structures  outside  of  the  epiphysial  cartilage,  thus  preserving 
the  centres  of  growth.  The  practical  importance  and  value  of 
the  suggestions  made  by  Tiling  will  be  appreciated  more  and 
more,  as  their  application  in  resection  of  the  different  joints  will 
do  much  toward  diminishing  extensive  shortening  after  resection 
of  the  large  joints  and  in  obtaining  otherwise  better  functional 
results. 

REPRODUCTION    OF   JOINT-STRUCTURES   AFTER   RESECTION. 

One  of  the  great  questions  in  connection  with  resection  of 
joints  is  in  reference  to  the  extent  the  structures  removed  are 
reproduced  after  the  operation.  This  subject  has  an  important 
bearing  on  the  functional  results  obtainable  by  the  operation. 
This  matter  has  received  the  careful  attention  of  surgeons  for 
more  than  a  century,  and  valuable  experimental  and  clinical 
studies  have  been  made;  yet  a  great  deal  remains  to  be  done 
before  definite  conclusions  can  be  drawn.  The  tendency  among 
surgeons  at  the  present  time  is  to  devise  methods  of  operation 
which  will  leave  the  parts  in  a  condition  better  adapted  to  re- 
production of  the  joint-structures  removed  than  was  the  case 
after  the  older  operations.  It  is  now  the  prevailing  idea  that 
only  diseased  tissue  should  be  removed,  and  as  little  of  the 
healthy  bony  structure  sacrificed  as  is  compatible  with  a  thorough 
operation.  This  applies  more  particularly  to  operations  on 


300  TUBERCULOSIS   OF   THE   BONES  AND   JOINTS. 

joints  where  it  is  desirable  to  procure  a  movable  joint  in  order 
to  obtain  the  best  functional  result,  as  the  shoulder-  and  elbow- 
joints.  The  first  effort  to  study,  experimentally,  the  reproduc- 
tion of  joints  after  resection,  in  a  systematic  manner,  was  made 
by  Steinlein  in  1849("Ueber  den  Heilungsprocess  nach  Re- 
section der  Knochen."  Dissertation,  Zurich,  1849). 

Vermandois  (Journal  de  Medecine,  T.  Ixvi)  was  the  first  to 
resect  the  upper  end  of  the  femur,  immediately  below  the  tro- 
chanter  minor,  in  a  dog.  The  wound  healed  in  two  months  by 
granulation.  At  this  time  the  animal  had  partial  use  of  the 
limb.  It  was  killed  and  the  new  joint  carefully  examined.  The 
resected  end  was  found  covered  with  irregular  prominences  of 
new  bone,  and  was  connected  by  a  strong  ligamentous  mass  with 
the  acetabulum.  The  circumference  of  the  acetabulum  was 
diminished  in  size,  and  the  cavity  was  filled  with  a  red  sub- 
stance, which  Vermandois  regarded  as  enlarged  and  injected 
synovial  glands.  This  experiment  on  the  same  animal  was 
repeated  later  by  Chaussier  (Magasin  Encycloped.,  An.  v,  T.  vi, 
No.  24).  Koeler,  like  some  of  the  earlier  expermenters  ("  Ex- 
perimenta  circa  regenerationem  ossium."  Goettingen,  1786), 
Wachter  ("  De  Articulis  extirpandis,"  etc.  Groningen,  1810), 
and  Heine  (Feigel,  "  Chirurgischer  Atlas."  Wiirzburg,  1850) 
obtained  substantially  the  same  results.  The  results  appeared 
to  be  about  the  same  whether  the  wound  healed  by  primary  or 
secondary  intention.  During  the  first  four  or  five  weeks  the 
limb  operated  on  was  useless,  but  from  this  time  on  function 
returned  speedily,  so  that  about  the  tenth  week  the  animal  made 
good  use  of  it.  In  dogs  killed  two  months  to  four  years  after 
the  operation  the  resected  end  of  the  femur  was  usually  found 
enlarged  by  uneven,  irregular  masses  of  bone ;  less  frequently 
it  presented  a  smooth  surface,  but  no  attempts  at  the  formation 
of  a  new  head  or  trochanter  were  observable  in  any  of  the 
specimens.  The  acetabulum  was  usually  found  deprived  of  its 
cartilaginous  lining  and  filled  in  with  firm  connective  tissue  or 
new  bone.  The  upper  end  of  the  femur  was  generally  found 


,E  rir  fl, 

r  :  301 

•;  h  '•l"ir,F.r,m: 

near  the  pelvis,  either- opposite  the  acetabulum  or  above  or 
behind  it.  The  connection  between  the  resected  end  of  the 
bone  and  the  pelvis  was  established  by  ligamentous  tissue,  which 
either  represented  a  capsule  which  embraced  the  end  of  the 
bone  on  one  side  and  on  the  other  side  was  attached  over  a 
considerable  surface  of  the  pelvic  bones,  or,  when  the  wound 
healed,  by  granulation  in  the  shape  of  firm  bands  of  connective 
tissue.  If  union  between  the  resected  end  and  the  acetabulum 
was  established  by  the  interposition  of  a  capsule,  this  often  was 
found  to  contain  a  fluid  which  resembled  synovia.  If  the  end 
of  the  bone  rested  against  the  bony  pelvic  wall  the  latter 
showed  a  superficial  depression  for  the  reception  of  the  club- 
shaped  end  of  the  femur.  In  most  of  the  cases  the  limb  was 
more  or  less  shortened.  In  the  experiments  in  which  Heine 
removed  not  only  the  upper  end  of  the  femur,  but  also  the 
acetabulum,  he  found,  months  after  the  operation,  on  making 
the  post-mortem,  the  site  of  the  articular  surface  of  the  pelvic 
bone  covered  with  masses  of  new  bone,  against  which  the  end 
of  the  femur  rested  without  bony  union  having  taken  place. 
The  resected  surfaces  were  connected  by  a  strong,  fibrous  cap- 
sule, which  contained  a  serous  fluid.  In  two  complete  resec- 
tions of  the  shoulder-joint  in  dogs  the  same  experimenter  found, 
after  the  expiration  of  nearly  a  year,  in  one  case  the  resected 
end  rounded  and  connected  by  bands  of  cicatricial  tissue,  while 
in  tKe  other  specimen  the  rounded  end  of  the  humerus  rested 
in  a  corresponding  circular  depression  of  the  scapula,  and  both 
were  connected  by  a  capsule,  and  the  surfaces  of  the  new  ar- 
ticular ends  covered  by  cartilage,  and  between  the  cartilage 
surfaces  a  meniscus  was  interposed.  The  same  author  made  a 
complete  resection  of  the  elbow  in  a  dog,  and  examined  the 
specimen  eighty-four  days  after  the  operation.  The  humeral 
end  was  covered  with  large  masses  of  bone,  representing  ap- 
proximately the  condyles,  which  served  as  points  of  attachment 
of  different  muscles.  The  connection  between  the  ends  of  the 
bone  had  become  established  in  part  by  remnants  of  the  cap- 


- 

,ii v/vqorn  cv3    ^w 

302  TUBERCULOSIS  OP    THE   BONES   AND   JOINTS. 

•ai03!MU» 

sule  and  in  part  by  muscular  adhesions.  He  also  obtained 
almost  complete  regeneration  of  parts — removed  subperiosteally 
— of  the  lower  end  of  the  radius  and  ulna  in  dogs.  Wachter 
examined  the  parts  three  months  after  such  an  operation,  and 
found  the  new  bone  at  the  end  of  the  radius  almost  as  volumi- 
nous as  in  a  normal  bone,  surrounded  by  a  new  and  thick 
capsule,  forming  almost  a  perfect  joint. 

A.  Wagner  ("  Ueber  den  Heilungs-process  nach  Resection 
und  Extirpation  der  Knochen."  Berlin,  1853)  resected  the 
head  of  the  humerus,  with  or  without  a  portion  of  the  shaft,  in 
nine  rabbits.  In  most  instances  suppuration  occurred,  attended 
by  sequestration  of  a  ring  of  bone,  which  prolonged  the  heal- 
ing process  often  for  weeks  and  months.  In  nearly  all  of  the 
specimens  he  found  the  resected  end  of  the  humerus  enlarged 
and  rounded  by  masses  of  new  bone,  and  a  more  or  less 
perfect  capsule  connecting  it  with  the  glenoid  cavity  of  the 
scapula.  In  a  number  of  specimens  he  found  the  inner  sur- 
face of  the  capsule  lined  with  pavement  epithelium,  but  he 
was  unable  to  detect  evidences  of  the  formation  of  new  articular 
cartilage. 

Bajardi  (Virchow  u.  Hirsch,  Jahresbericht,  B.  ii,  1882,  p. 
337)  made  numerous  experiments  on  young  dogs  in  order  to 
study  the  reproduction  of  the  articular  extremities  after  sub- 
periosteal  and  subcapsular  resections.  He  found  that  the  re- 
sected ends  are  reproduced  to  perfection,  becoming  gradually 
covered  with  articular  cartilage.  The  new  articular  extremity 
is  produced  from  the  periosteum  of  the  shaft  of  the  bone,  from 
the  medulla,  and  to  a  lesser  degree  from  the  connective  tissue 
which  covers  the  sawn  surface.  The  new  formation  commences 
in  the  medullary  tissue  in  the  form  of  embryonal  connective 
tissue,  which  is  transformed  partly  into  bone  and  partly  into 
cartilage.  The  periosteum  and  connective  tissue  take  an  active 
part,  at  a  later  stage,  in  the  reproduction  of  tissue.  The  results 
obtained  by  experiments,  in  establishing  the  fact  that  partial  re- 
production of  joints  takes  place  after  resection,  have  received 


RESECTION.  303 

strong  confirmation  from  carefully-made  clinical  observations, 
combined  with  post-mortem  examinations. 

Textor  ("  Ueber  die  Wiedeierzeugung  der  Knochen  nach 
Resectionen  bei  Menscben."  Wiirzburg,  1843)  had  the  unusual 
opportunity  to  examine  the  conditions  after  resections  of  the 
shoulder-joint,  nineteen,  eleven,  and  six  years  after  the  opera- 
tion. In  two  of  the  specimens  he  found  marked  evidences  of 
reproduction  of  bone.  In  one  of  the  specimens  the  new  bone 
was  represented  by  a  long  process  resembling  somewhat  the 
styloid  process  of  the  ulna,  while  in  another  instance  the  new 
bone  deposited  upon  the  resected  end  was  a  quarter  of  an  inch 
in  thickness  and  presented  an  uneven  surface.  One  of  the 
elevations  of  the  new  disc  of  bone  served  as  a  point  of  attach- 
ment for  the  long  head  of  the  biceps  muscle,  while  another  pro- 
jection rested  in  a  depressed  portion  of  the  glenoid  cavity  of  the 
scapula.  In  the  case  that  survived  the  operation  nineteen 
years,  he  found  a  movable  meniscus  interposed  between  the  new 
bone  and  the  glenoid  cavity.  In  one  of  his  patients  a  new  and 
almost  perfect  capsule  had  formed,  which  below  embraced  the 
upper  one-fourth  of  the  resected  humerus.  The  meniscus  was 
composed  of  the  same  tissue  covering  the  new  bone  deposited 
upon  the  resected  end  of  the  humerus.  Syme  ("  Treatise  on 
the  Excision  of  Diseased  Joints."  Edinburgh,  1831)  verified 
the  anatomical  conditions  by  a  careful  post-mortem  examination 
in  two  of  his  cases  of  resection  of  the  shoulder-joint, — in  one 
case  six  months,  and  in  the  other  case  ten  years, — after  the 
operation.  In  both  of  them  lie  found  the  resected,  rounded  end 
of  the  humerus  connected  with  the  scapula  by  firm  ligamentous 
tissue. 

Say  re  ("  Specimen  of  Reproduction  of  the  Hip- Joint  After 
Exsection,"  etc.  Transactions  of  International  Medical  Con- 
gress, 1881)  has  recorded  the  most  perfect  result  obtainable  in 
resection  of  the  hip-joint.  He  had  an  opportunity  to  make  a 
post-mortem  examination  on  a  patient  who  died  of  amyloid  de- 
generation of  the  liver  and  kidneys  three  and  a  half  years  after 


304  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

resection  of  the  hip-joint,  in  a  child  7  years  of  age.  In  spite  of 
the  persistence  of  a  suppurating  sinus,  perfect  regeneration  of  the 
joint-structures  had  taken  place.  Head,  neck,  and  trochanter, 
as  well  as  articular  and  epiphysial  cartilages  and  capsule,  were 
perfect.  The  microscopic  examination  made  by  Heitzmann 
corroborated  the  anatomical  and  macroscopical  appearances. 

Textor  (ibid.,  p.  13)  describes  an  elbow-joint  which  formed 
after  resection,  as  follows:  "The  ulna  was  elongated  one 
quarter  of  an  inch,  upon  which  the  radius  revolved  as  in  a  nor- 
mal joint.  The  trochlea  of  the  humerus  was  as  perfect  as 
though  the  lower  end  of  this  bone  had  never  been  removed." 
In  this  specimen  the  triceps  muscle  was  found  firmly  united 
with  the  cicatrix  in  the  skin. 

Oilier  examined  anatomically  a  new  elbow-joint  eight  years 
after  resection.  The  patient  was  27  years  old  when  the  opera- 
tion was  performed,  and  died  eight  years  later.  He  found  the 
articular  ends  fully  as  well  developed  as  in  the  intact  joint,  and 
covered  by  a  thin  layer  of  chondroid  substance  in  place  of  artic- 
ular cartilage.  The  synovial  membrane  had  been  reproduced 
and  showed  several  compartments,  while  the  capsule  was  as 
perfect  as  that  of  a  normal  joint.  The  function  of  the  joint  was 
nearly  perfect.  J.  Wolff  ("  Ueber  einen  Fall  von  Ellenbogen 
gelenk-Resection,  nebst  Bemerkungen  iiber  die  Frage  von  den 
End  resultaten  der  Gelenk  resectionen."  Archiv  f.  Hin.  Chirur- 
gie,  B.  xx,  p.  771)  made  a  complete  resection  of  an  elbow-joint 
in  a  child  2-|  years  of  age,  and  three  years  later  was  able  to 
satisfy  himself — from  the  almost  complete  restoration  of  function 
which  had  taken  place  and  a  careful  examination  of  the  arm — 
that  an  almost  perfect  joint  had  formed,  including  the  reproduc- 
tion Of  the  olecranon  process  and  the  head  of  the  radius.  A. 
Wagner,  and  to  a  lesser  degree,  Oilier,  had  doubted  that  such 
a  perfect  result  could  be  obtained.  This  case  and  others  prove 
conclusively  that  under  favorable  circumstances  almost  perfect 
reproduction  of  the  parts  removed  can  take  place.  Reliable 
cases  of  almost  complete  restoration  of  the  shoulder-joint  after 


RESECTION.  305 

resection  have  been  reported  by  Luecke;  of  the  ankle-joint,  by 
Doutrelepont,  Heinemann,  Czerny,  Jagetho,  and  Weichselbaum ; 
of  the  elbow-joint,  by  Syme  and  Textor.  Two  forms  of  joints 
have  been  described  as  observed  after  resection  of  the  elbow- 
joint.  In  the  first  variety  the  olecranon  is  not  reproduced,  or 
it  exists  only  in  a  rudimentary  form.  In  such  a  case  the  sig- 
moid  cavity  of  the  ulna  and  the  trochlea  of  the  humerus  are 
absent.  Lateral  deviation  of  the  forearm  during  flexion  and 
extension  is  prevented  by  the  condyles  of  the  humerus,  which 
are  well  developed  and  embrace  the  convex  end  of  one  or  both 
bones  of  the  forearm.  Such  a  result  has  been  described  by 
Syme,  Czerny,  Jagetho,  and,  perhaps,  Ollier's  case  belongs  in 
the  same  category.  In  the  second  variety  the  restoration  of  the 
structure  and  function  approaches  more  nearly  a  perfect  joint. 
The  olecranon  process  of  the  ulna  and  trochlea  of  the  humerus 
are  almost  perfect, — conditions  which  insure  an  almost  perfect 
ginglymus  joint.  Preservation  of  periosteum  and  other  struc- 
tures of  the  joint,  not  affected  by  the  disease  or  injury  which 
has  made  the  operation  necessary,  is  an  essential  factor  in  ob- 
taining restoration  of  structure  and  function  approaching  a 

perfect  joint. 

ao 


CHAPTER  XXVII. 

ATYPICAL  AND  TYPICAL  RESECTION. 

IN  the  treatment  of  tubercular  joints  in  children,  atypical 
will  more  and  more  take  the  place  of  typical  resection.  If,  by 
this  operation,  a  good  and  useful  position  of  the  limb  can  be 
obtained  and  all  of  the  diseased  tissues  can  be  removed,  it 
seems  to  me  it  is  the  ideal  operation  for  all  cases  in  which  the 
capsule  and  a  part  of  the  articular  surfaces  require  operative 
removal.  As  to  the  question  of  typical  resection,  with  saw- 
ing off  of  the  entire  ends  of  the  articular  extremities  of  the 
bones,  Mr.  Barker  (British  Medical  Journal,  June,  1888)  pre- 
dicts that,  after  a  few  years,  when  the  principles  underlying  the 
treatment  of  tubercular  disease  are  better  understood  and  the 
necessity  of  early  operation  will  be  more  generally  recognized, 
such  operations  will  be  some  of  the  rarest  in  surgery,  and  will 
be  replaced  entirely  by  the  extirpation  of  localized  foci  in  the 
bones,  without  any  sacrifice  of  their  length  and  growing  power. 
The  external  incision  in  atypical  and  typical  resection  of  joints 
should  be  the  same.  Incisions  which  procure  most  ready  access 
to  all  parts  of  the  joint  and  that  interfere  least  with  the  attach- 
ment of  important  muscles  should  be  selected.  It  is  often  only 
after  the  joint  has  been  opened  by  such  an  incision  that  the 
surgeon  is  in  a  position  to  make  an  intelligent  choice  between 
arthrectomy,  atypical  and  typical  resection.  In  operating  on 
the  knee-joint  after  the  external  incision  is  made  the  patella  is 
divided  transversely,  and,  if  it  does  not  contain  a  tubercular 
focus,  it  is  not  necessary  or  advisable  to  remove  this  bone,  as  its 
continuity,  after  resection,  can  be  restored  by  suturing  with  a 
durable  form  of  catgut.  An  atypical  resection  for  tuberculosis 
consists  in  extirpation  of  the  tubercular  capsule  and  of  the  re- 
moval of  tubercular  foci  in  the  epiphysial  extremities  of  the  bones 
that  enter  into  the  formation  of  the  joint,  without  removing  the 
entire  -articular  extremities  by  a  transverse  section  with  the  saw, 
(306) 


ATYPICAL    AND    TYPICAL    RESECTION.  307 

The  unnecessary  removal  of  the  epiphysial  extremities  should 
especially  be  avoided  in  the  case  of  young  children,  as  the 
removal  of  one  or  both  centres  of  growth  of  bone  will  result 
only  too  often  in  so  much  shortening  of  the  limb  subsequently 
as  to  render  it  not  only  perfectly  useless,  but  it  becomes  fre- 
quently, at  the  same  time,  a  burdensome  appendage.  In  chil- 
dren atypical  resection  should  be  practiced  in  all  cases  ivhere  all 
the  foci  in  the  articular  extremities  can  be  reached  and  removed 
by  this  method.  The  proper  instruments  to  be  used  in  this 
operation  are  the  chisel,  bone-forceps,  sharp  spoon,  catch-forceps, 
and  curved  scissors.  After  the  joint  has  been  freely  opened  the 
articular  surfaces  are  carefully  inspected  for  evidences  of  super- 
ficial and  deeply-seated  osseous  foci.  In  primary  synovial  tu- 
berculosis, with  circumscribed  superficial  erosions  of  the  bone, 
the  latter  are  to  be  scooped  out  thoroughly  by  free  use  of  the 
sharp  spoon.  If  perforation  into  the  joint  from  an  osseous 
focus  has  taken  place  the  cavity  is  freely  exposed  from  the 
articular  surface,  and  all  of  the  infected  tissues  are  removed 
with  chisel  and  sharp  spoon.  It  is  important  not  only  to 
remove  necrosed  bone,  granulation  tissue,  and  caseous  material, 
but  also  the  surrounding  osteoporotic  zone  of  bone  that  possi- 
bly might  contain  tubercle  bacilli.  A  deep-seated  focus  may 
be  suspected,  and  should  be  searched  for,  if  the  articular  car- 
tilage has  become  detached  over  a  greater  or  less  extent.  Ex- 
plorations with  a  small  perforator  can  be  made  in  different 
directions  from  the  articular  surface  in  searching  for  deeply- 
seated  foci.  A  circumscribed  area  of  great  vascularity  is  a  sus- 
picious  indication,  and  calls  for  a  limited  excavation,  with  a 
sharp,  small  spoon,  for  diagnostic  purposes.  It  is  well  for  the 
surgeon  to  remember  that  primary  osteotuberculosis,  with  sec- 
ondary involvement  of  a  joint,  usually  consists  of  more  than 
one  focus  in  one  or  both  articular  extremities.  A  tubercular 
infarct  is  generally  recognized  by  examining  the  articular  sur- 
face, as  the  cartilage  or  the  exposed  portion  of  the  wedge- 
shaped  sequestrum  presents  typical  appearances  of  necrosis  that 


308 


TUBERCULOSIS   OF   THE    BONES   AND    JOINTS. 


cannot  be  mistaken.  After  the  extraction  of  the  sequestrum 
the  tubercular  cavity  is  subjected  to  the  same  treatment  as  when 
dealing  with  a  granulating  or  caseous  focus.  If  the  pathologi- 
cal conditions  are  such  as  to  require  removal  of  one  of  the 
condyles  of  the  femur,  or  one  of  the  tuberosities  of  the  tibia 
beyond  the  epiphysial  line,  in  resection  of  the  knee-joint,  the 
operation  need  not  consist  in  making  a  complete  resection  of 
the  articular  extremity,  as  a  better  functional  result  can  be 
obtained  by  removing  from  the  opposite  bone  and  side  of  the 
articular  extremity  a  section  of  bone  corresponding  in  size  and 
depth  to  the  part  of  the  articular  extremity  on 
the  side  where  the  section  was  made.  The 
resected  ends  then  overlap  each  other,  and  a 
firm,  bony  union  can  be  confidently  expected. 
By  following  this  plan  the  resected  ends 
are  spliced,  as  it  were,  thus  securing  a  large 
surface  of  bone  for  coaptation  and  the  forma- 
tion of  a  firm,  bony  union,  in  good  position 
of  the  limb,  without  removing  the  entire  epi- 
physial centre  of  growth  of  either  of  the  bones. 
I  have  adopted  this  plan  in  several  cases  of 
atypical  resection  of  the  knee-joint,  and  the 
FIG.  37.— ATYPICAL  operation  was  always  followed  by  #ood  opera- 

RESECTION  OF  KNEE-  rf  '    c 

JOINT,  WITH  SPLIC-    tive  an{j  functional  results. 


ING      OF 

ENDS. 


ARTICULAR 


In  primary  synovial  tuberculosis,  with 
extension  of  the  disease  to  the  subjacent  bone,  it  becomes  neces- 
sary to  remove  the  honey-combed,  softened  bone  over  the  entire 
surface  affected,  with  sharp  spoon  and  chisel.  Before  the  opera- 
tion is  extended  to  the  bone  in  osteotuberculosis  requiring  atypi- 
cal resection,  it  is  always  necessary  first  to  extirpate,  with  knife 
and  scissors,  the  infected  soft  structures  of  the  joint,  the  syno- 
vial membrane,  and  ligaments,  as  otherwise  the  healthy  vascular 
bone  may  become  an  infection-atrium  for  traumatic  dissemina- 
tion,— a  not  very  infrequent  and  serious  complication  after 
operations  on  bones  and  joints  for  tubercular  affections.  Carti- 


ATYPICAL   AND   TYPICAL   RESECTION.  309 

lage  that  remains  firmly  attached  to  the  bone  may  be  left.  After 
all  foci  have  been  radically  eliminated  the  field  of  operation  is 
flushed  with  an  antiseptic  solution,  and,  after  drying  and  iodo- 
fbrmization,  the  bone-cavities  are  packed  with  decalcified  anti- 
septic bone-chips,  and  the  operation  is  completed  in  the  same 
manner  as  in  arthrectomy. 

I  always  use  iodine-water  made  by  adding  tincture  of  iodine 
to  sterilized  water  until  the  solution  represents  in  color  dark 
sherry-wine.  This  preparation  was  used  long  ago  by  Pirogoff 
(Selenkow,  "  Zur  operativen  Behandlung  der  Tubcrculose." 
St.  Petersburger  Med.  Woclienscrift,  No.  19,  1884),  who  em- 
ployed a  10-per-cent.  solution  of  iodine,  which  he  injected 
through  the  drainage-tubes  after  the  resection  wound  was 
sutured.  This  injection  he  repeated  in  from  three  to  four  days. 
Since  he  resorted  to  this  method  of  disinfection  the  results  of 
the  resections  in  the  hands  of  this  distinguished  surgeon  were 
much  more  satisfactory.  The  treatment  of  bone-cavities  with 
decalcified  bone-packing  is  of  the  greatest  utility  in  atypical 
resection.  An  atypical  resection  with  subsequent  implantation 
of  decalcified  bone  has  for  its  object  complete  removal  of  the 
infected  tissues  in  the  joint  and  the  surrounding  bone,  and  the 
partial  restoration  of  the  parts  destroyed  by  disease  or  removed 
during  the  operation.  In  atypical  resection  of  the  knee-joint  it 
is  not  uncommon  that  nearly  an  entire  condyle  of  the  femur  or 
tuberosity  of  the  tibia  must  be  removed.  If  in  such  cases  the 
external  compact  layer  of  bone  can  be  preserved,  this  should  be 
done  and  bony  union  in  good  position  secured, — a  result  which 
can  be  accomplished  in  the  most  satisfactory  manner  by  placing 
the  parts  in  a  condition  to  repair  the  lost  bone-tissue,  which  can 
be  done  by  filling  the  defect  with  decalcified  bone-chips.  I 
have  repeatedly  made  excavations  in  one  of  the  condyles  of  the 
femur  and  in  the  head  of  the  tibia  from  the  joint  surface,  the 
size  of  a  small  orange,  and  obtained  bony  union,  with  the  limb 
in  a  good  position,  by  filling  the  cavities  with  bone-chips,  and 
the  time  required  to  obtain  consolidation  of  the  articular  ends 


310  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

and  the  restoration  of  lost  bone-tissue  did  not  exceed  the  time 
necessary  to  unite  a  subcutaneous  fracture  in  the  upper  portion 
of  the  tibia  or  the  lower  part  of  the  femur.  As  the  bone-chips 
are  always  iodoformized  before  implantation,  they  serve  a  useful 
purpose,  not  only  by  furnishing  a  temporary  scaffolding  for  the 
reparative  material,  but  they  constitute  at  the  same  time  a 
valuable  therapeutic  measure,  in  the  prevention  of  a  local  recur- 
rence of  the  disease  in  case  tubercle  bacilli  should  remain  in  the 
cavity  or  its  immediate  vicinity.  At  the  same  time  the  bone- 
packing  serves  the  purpose  of  an  absorbable  tampon,  which  pre- 
vents excessive  oozing  from  the  cavity  after  the  operation.  A 
capillary  drain  inserted  into  the  outer  and  inner  angle  of  the 
wound  will  answer  the  purpose  of  drainage.  Immobilization  of 
the  limb  after  resection  should  be  continued  until  the  process 
of  repair  has  been  completed,  which,  under  the  most  favorable 
conditions,  requires  from  six  weeks  to  two  months.  Atypical 
resections  are  applicable  only  to  certain  joints, — as  the  knee, 
elbow,  and,  to  a  lesser  extent,  the  ankle,  tarsal,  and  carpal 
joints.  The  elbow-joint  is  most  accessible  through  a  long, 
straight,  posterior  incision,  and  after  temporary  resection  of  the 
olecranon  process.  Partial  resection  of  the  ankle-joint  can  be 
done  through  two  lateral  incisions,  with  chisel  and  sharp  spoon. 
In  all  resections,  atypical  and  typical,  ignipuncture  is  indicated 
after  the  excision  has  been  completed  if  any  portion  of  the  bone 
is  abnormally  osteoporotic,  as  this  procedure  will  stimulate  the 
process  of  repair,  and  may  prove  useful  in  destroying  infected 
tissues,  which,  from  their  macroscopical  appearance,  indicate  a 
healthy  condition. 

Typical  Resection. — In  typical  or  complete  resection  the 
synovial  membrane  and  ligaments  of  the  joint  are  extirpated 
completely;  at  the  same  time,  one  or  both  articular  extremities 
are  sawn  across  and  removed.  In  the  hip-joint  this  operation, 
aside  from  the  extirpation  of  the  soft  structures  of  the  joint,  aims 
at  the  removal  of  the  head,  neck,  and  part  or  the  whole  of  the 
greater  trochanter  of  the  femur.  A  typical  resection  of  the 


ATYPICAL   AND    TYPICAL   RESECTION. 


311 


wrist-joint  implies  the  removal  of  the  entire  carpus,  with  or 
without  the  articular  surfaces  of  the  radius,  ulna,  and  metacar- 
pal  bones.  In  a  complete  resection  of  the  shoulder-joint  the 
head  of  the  humerus  is  removed.  In  the  knee-joint  the  same 
operation  implies  excision  of  the  articular  surfaces  of  the  femur 


FIG.  38.— KONIG'S  OPERATION  or  RESECTION  OF  THE  HIP-JOINT. 

c  f,,  the  two  trochanteric  borders  separated  and  turned  away  from  the  bone  ;  6,  central  of  trochanter,  which 
is  to  be  removed  by  cutting  toward  the  base  of  the  neck  of  the  femur. 

and  tibia;  in  the  elbow-joint,  of  the  humerus,  radius,  and  ulna; 
in  the  ankle,  of  the  tibia,  fibula,  and  astragalus.  Typical  resec- 
tions are  generally  made  for  tubercular  affections  of  the  shoulder-, 
hip-,  and  wrist-  joints.  In  the  remaining  large  joints  it  is  more 
frequently  resorted  to  in  adults  than  children.  In  children  the 


312  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

operation  is  limited,  with  the  exception  of  the  shoulder-,  hip-, 
and  wrist-  joints,  to  cases  where  the  articular  extremities  are  so 
extensively  diseased  that  an  atypical  resection  would  fail  in  re- 
moving all  of  the  infected  tissues.  Extirpation  of  the  diseased 
synovial  memhrane  and  ligaments  should  precede  section  of  the 
bones  with  the  saw  or  chisel  whenever,  from  the  anatomical 
construction  of  the  joint,  this  can  be  done.  In  the  hip-  and 
shoulder-  joints  the  head  of  the  bone  must  be  removed  first  be- 
fore the  soft  structures  of  the  joint  can  be  extirpated.  One  of 
the  best  adapted  operations  for  resection  of  the  hip-joint  is  the 
one  devised  by  Konig,  by  which  the  anterior  and  posterior 
borders  of  the  trochanter  major  are  preserved.  In  this  opera- 
tion the  section  of  the  bone  must  be  made  with  a  chisel.  The 
entire  head  and  neck  of  the  femur  are  removed  by  dividing  the 
bone  transversely  with  a  chisel  just  below  the  neck,  with  the 
exception  of  the  borders  of  the  great  trochanter,  which  are  split 
off  with  the  same  instrument. 

The  capsular  ligament  is  removed  as  thoroughly  as  pos- 
sible, and  the  acetabulum  is  scraped  out  with  a  sharp  spoon. 
Provision  for  drainage  must  be  made  in  all  hip-joint  resections. 

In  order  to  prevent  accumulation  of  blood  in  resection 
wounds,  and  for  the  purpose  of  securing  more  thorough  iodo- 
formization  of  the  surfaces,  it  has  recently  been  customary, 
especially  in  Germany,  to  resort  to  iodoform  tamponade  and 
secondary  suture. 

Bramann  ("  Ueber  Wundbehandlung  mit  Iodoform  tam- 
ponade." Archiv  f.  Minische  Chirurgie,  B.  xxxvi,  p.  72)  has 
published  the  results  of  this  modification  of  wound  treatment  in 
resection  of  joints  from  April,  1884,  to  end  of  July,  1886.  The 
iodoform-gauze  tampon  is  made  large  enough  to  exert  gentle 
pressure  against  the  surfaces  of  the  wound,  and  is  allowed  to 
remain  from  two  to  three  days,  when  it  is  removed  and  the 
wound  sutured  and  dressed  in  the  usual  manner. 

Resection  of  Hip-Joint  (  Thirty-four  Cases}. — Tampon  re- 
moved after  forty-eight  hours.  No  death  from  immediate  effect 


ATYPICAL   AND   TYPICAL   RESECTION.  313 

of  operation.  Final  result  not  known,  6 ;  cured,  21 ;  discharged 
with  fistula,  4 ;  died  later,  wound  healed,  2 ;  died  later,  wound 
not  healed,  1. 

Resection  of  Knee-Joint  and  Arthrectomy  (Twenty-one 
Cases}. — Tampon  removed  and  wound  sutured  after  two  to 
three  days.  Cured,  16 ;  result  not  known,  1 ;  discharged  with 
fistula,  2 ;  three  deaths,  six  to  eighteen  months  later,  from  pul- 
monary phthisis;  cured  later,  1;  died,  1.  In  most  cases  re- 
covery with  ankylosis. 

Resection  of  Ankle-Joint  (Eight  Cases). — Cured,  1 ;  am- 
putated later,  3 ;  wound  not  healed,  and  death  from  pulmonary 
tuberculosis  several  months  after  operation,  4. 

Resection  of  Shoulder- Joint  (Three  Cases). — Cured  (chil- 
dren), 2;  died,  patient  60  years  old,  three  weeks  later,  from 
pulmonary  phthisis,  1. 

Resection  of  Elboiv-Joint  (Eleven  Cases).  —  Discharged 
cured,  6;  discharged  with  fistula,  4;  chloroform  death,  1. 
Final  result :  Cured,  7 ;  wound  not  healed,  2 ;  died,  2 ;  func- 
tional result  in  three  cases  excellent. 

Resection  of  Wrist-Joint  (Tico  Cases). — In  both  cases 
wound  healed,  but  functional  result  imperfect.  Helferich  ("  Die 
praktische  Bedeutung  der  Sekundaren  Naht."  Munch.  Med. 
Wochenschrift,  Nos.  20,  21,  1887),  although  in  favor  of  this 
method  of  treatment,  objects  to  the  tampon  and  secondary 
suture  in  resection  of  the  knee-joint.  At  the  last  meeting  of 
the  International  Medical  Congress,  von  Bergman n  presented, 
in  the  Surgical  Section,  a  number  of  cases  that  had  recently 
been  operated  on  by  this  method,  and  every  one  who  had  the 
privilege  of  seeing  the  cases  and  of  listening  to  the  remarks  of 
this  distinguished  surgeon  became  convinced  of  its  merits.  It 
is  more  especially  useful  in  the  treatment  qf  resection  wounds 
in  which  it  is  impossible  to  prevent  "  dead  spaces  "  by  suturing. 
I  am  in  accord  with  Helferich  in  advising  against  its  employ- 
ment in  resection  of  knee-joint,  as  in  such  cases  the  wound  sur- 
faces can  and  should  be  brought  in  permanent  and  uninterrupted 


314  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

contact  immediately  after  the  excision,  and  the  parts  should  be 
disturbed  as  little  as  possible  subsequently. 

Bramann  mentions,  as  one  of  the  disadvantages  of  this 
treatment,  the  necessity  of  placing  the  patient  under  the  influ- 
ence of  anesthesia  at  the  first  dressing.  This  objection  I  have 
overcome  by  introducing  the  sutures  at  the  time  of  operation 
and  tying  the  ends  loosely  together  over  the  dressing.  The  re- 
moval of  the  gauze  and  tying  of  the  sutures  can  be  done  with- 
out anesthesia.  The  after-treatment,  in  excision  of  the  hip  by 
this  method,  consists  of  rest  in  bed  upon  a  smooth  mattress,  with 
the  limb  extended  by  weight  and  pulley  in  an  abducted  position. 
After  six  weeks  the  patient  is  allowed  to  walk  on  crutches,  with 
a  raised  sole  under  the  shoe,  worn  on  the  opposite  side,  so  that 
the  limb  on  the  resected  side  swings  freely  and  makes  the  neces- 
sary auto-extension.  During  the  night  extension  is  kept  up  for 
eight  months  or  a  year,  in  order  to  prevent  unnecessary  short- 
ening. Eversion  and  inversion  of  the  limb  while  the  patient  is 
in  bed  are  prevented  either  by  a  Volkmann  railway-splint,  or  by 
supporting  the  limb  with  sand-bags,  applied  to  each  side.  Im- 
mobilization, after  resection  of  the  shoulder-,  elbow-,  wrist-, 
knee-,  and  ankle-  joints,  is  best  secured  in  a  plaster-of-Paris 
dressing,  which  also  serves  an  excellent  purpose  in  keeping  the 
antiseptic  dressing  in  situ.  Instead  of  a  circular  splint,  a  pos- 
terior splint  made  of  the  same  material  can  be  made,  as  advised 
by  Sayre  and  others.  Temporary  resection  of  the  olecranon 
process,  in  excision  of  the  elbow-joint,  has  yielded  excellent  re- 
sults in  my  hands,  as  by  it  the  insertion  of  the  triceps  muscle  is 
not  disturbed.  The  resected  olecranon,  after  the  removal  of 
any  foci  it  may  contain,  is  riveted  to  a  denuded  surface  of  the 
shaft  of  the  ulna  with  a  sterilized  ivory  or  bone  nail  after  the 
resection  has  been  completed,  or  it  is  fastened  with  two  durable 
catgut  sutures.  The  latter  method  of  coaptation  and  fixation 
I  employ  now  almost  exclusively.  The  forearm  is  immobilized 
in  a  semiflexed  position  until  bony  union  between  the  shaft  of 
the  ulna  and  olecranon  process  has  taken  place,  which  usually 


ATYPICAL   AND   TYPICAL    RESECTION.  315 

requires  from  four  to  six  weeks.  After  this  time,  passive  motion 
and  massage  should  be  made  to  increase  the  mobility  of  the 
joint.  A  straight,  single  incision  upon  the  posterior  side,  directly 
over  the  centre  of  the  olecranon  process,  is  the  one  which  affords 
best  access  to  the  elbow-joint,  with  the  least  injury  to  the  tissues 
around  the  joint.  A  straight,  single  incision  upon  the  dorsal 
side  is  best  adapted  for  resection  of  the  wrist-joint,  as  the  ex- 
tensor tendons  of  the  hand  and  ringers  can  be  drawn  aside 
sufficiently  to  afford  ample  room  for  the  removal  of  the  entire 
carpus.  In  the  after-treatment  of  excision  of  the  wrist,  the  fore- 
arm and  hand,  as  far  as  the  metacarpo-phalangeal  joints,  are 
encased  in  a  plaster-of-Paris  splint,  with  the  hand  in  a  slightly  ex- 
tended position  and  half-way  between  pronation  and  supination. 


PIG.  39.— BAKER'S  PINS  TO  HOLD  BONE  SURFACES  IN  APPOSITION.    (Brit.  Med.  Journal.) 

Immediate  fixation  of  the  resected  ends  by  means  of  aseptic 
bone  or  ivory  nails,  after  excision  of  the  knee  or  any  other  joint, 
is  superfluous,  as  the  parts  can  be  kept  in  accurate  position  by 
ordinary  external  fixation  dressings.  In  knee-joint  resections, 
the  section  through  the  bones  must  be  made  in  such  a  manner 
that  when  the  sawn  surfaces  are  brought  in  apposition  the  leg 
will  be  sligtly  flexed,  as  this  position  enables  the  patient  to  walk 
more  easily  and  gracefully  than  with  a  straight,  stiff  limb.  The 
artificial  support  must  not  be  removed  until  firm,  bony  union  has 
taken  place,  which  will  require  from  two  to  three  months, 
according  to  the  patient's  general  health  and  age. 


CHAPTER  XXVIII. 

IMMEDIATE  AND  REMOTE  RESULTS  OF  RESECTION. 

THE  value  of  all  surgical  interventions  in  the  treatment  of 
articular  tuberculosis  is  estimated  differently  by  different  sur- 
geons. The  immediate  and  remote  results  depend  largely  upon 
the  time  the  operation  is  made  and  the  thoroughness  with  which 
it  is  executed.  I  recollect  that  one  of  the  best  surgeons  of 
Germany  made  the  statement  to  me,  a  few  years  ago,  that  the 
results  of  his  operations  for  tubercular  affections  had  been 
greatly  bettered  since  he  had  been  on  a  visit  to  Bardenheuer 
and  had  witnessed  the  operations  of  this  bold  surgeon  for  dif- 
ferent forms  of  surgical  tuberculosis,  notably  excision  of  joints. 
The  operative  result,  like  in  operations  for  malignant  disease, 
will  be  better  from  year  to  year,  as  surgeons  are  becoming  more 
and  more  convinced  of  the  necessity  of  early  interference  and 
of  thorough  operating.  I  think  every  surgeon  of  large  experi- 
ence would  have  to  admit  that  the  results  of  his  early  operations 
do  not  compare  favorably  with  those  obtained  later,  as  his 
experience  increased.  In  order  to  present  to  the  reader  the 
different  prevailing  views  in  regard  to  the  immediate  and  re- 
mote results  of  resection  of  joints  for  tuberculosis,  I  will  quote 
authorities  from  different  countries  and  statistics  from  various 
sources.  In  1880  Mr.  Holmes,  in  his  address  on  surgery,  before 
the  British  Medical  Association,  referred  to  245  resections  of 
the  knee,  done  in  seven  of  the  largest  hospitals  in  London,  with 
a  mortality  of  21 ;  failures,  47 ;  of  which  latter  36  were  sub- 
jected to  amputation;  and  recoveries,  173.  Of  215  hip-joint 
resections  40  died,  57  proved  failures,  and  118  recovered. 

Wartmann  (Deutsche  Zeitschrift  f.  Chirurgie,  B.  xxiv,  p. 
435,  1887),  after  giving  a  careful  account  of  the  results  follow- 
ing excision  of  tubercular  joints  in  the  hospital  practice  of 
Feurer,  gives  the  statistics  of  837  cases  of  excision  of  joints  for 
tuberculosis,  from  the  practice  of  different  operators.  Of  this 
(316) 


IMMEDIATE   AND    REMOTE   RESULTS   OF   RESECTION.  317 

number  225  died.  Of  the  fatal  cases,  in  26  death  followed  the 
operations  closely,  and  resulted  from  acute  tuberculosis,  prob- 
ably induced  by  the  operation.  Schmid-Monnard  ("  Ueber  den 
Zeitrunkt  fur  Bestimmung  endgiiltiger  Resultate  der  Resection 
tuberculos  erkrankter  Gelenke."  Centralblatt  f.  Chirurgie, 
No.  52,  1889)  has  collected  from  several  large  clinics  cases  of 
joint  resection,  which  had  been  followed  from  two  and  one- 
fourth  to  fourteen  years  after  the  operation,  for  the  purpose  of 
ascertaining  the  final  results  and  the  causes  and  time  of  death 
of  the  fatal  cases.  Most  of  the  operations  were  done  since  the 
antiseptic  treatment  of  wounds  has  been  in  vogue.  He  col- 
lected 116  deaths,  and  from  the  tabulated  cases  it  can  be  seen 
that  80  per  cent,  of  this  number  died  within  two  years  after  the 
operation  and  the  balance  within  five  and  one-half  years,  with 
the  exception  of  2  cases,  in  one  of  which  death  resulted  in  six 
and  in  the  other  nine  years  after  the  resection.  Deaths  from 
tuberculosis  diminish  in  frequency  with  the  time  elapsed  since 
operation.  After  the  expiration  of  two  and  one-fourth  years 
probably  only  4  per  cent,  of  all  those  operated  on  die  of  tuber- 
culosis or  its  immediate  consequences.  The  results  quod  vitam 
at  this  time  are  nearly  final.  Of  2207  operations,  collected  in- 
differently from  the  hospitals  di  Midi,  Pitie,  Necker,  and  Hotel 
Dieu,  by  Thiery  ("  Traitement  Chirurgical  des  Tuberculoses 
Peripheriques  suites  immediates."  Etudes  experimentales  et 
Cliniques  sur  la  Tuberculose,  1888-1890,  p.  630),  262  were 
performed  for  local  tubercular  affections,  and  of  these  107  were 
done  for  tubercular  diseases  of  bones  or  joints.  These  cases 
were  divided  as  follows : — 

Humbert, 523  43 

Polaillon, 981  109 

Le  Fort,    .  , 210  35 

Verneuil, 492  _75 

Total, 2206  262 

The  above  cases  were  from  and  including  1886  to  1890. 
Two  hundred  and  sixty-two  were  tubercular;  with  the  following 
post-operative  results :  cured,  86 ;  improved,  92 ;  stationary, 


318  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

56 ;  local  aggravation,  8 ;  general  infection,  tubercular  menin- 
gitis, 6 ;  remaining  in  hospitals,  under  treatment,  3  ;  or,  in  other 
words:  result  satisfactory,  178  (22  mediocre)  ;  no  benefit  from 
operation,  56 ;  aggravation  of  disease,  local  or  general,  39  (14 
of  these  died).  The  opinions  of  French  surgeons  on  the  value 
of  the  operative  treatment  of  peripheral  tubercular  affections 
were  reflected  at  a  meeting  of  the  Tuberculosis  Congress,  when 
Verneuil  said :  "  We  have  reason  to  be  optimistic  when  it 
concerns  immediate  results." 

Oilier:  "The  most  favorable  cases  of  latent  tuberculosis — 
this  chronic,  prolonged  tuberculosis — would  have  more  than 
one  analogy  with  osteomyelitis ;  .  .  .  .  and  it  is  known 
that  operative  treatment  often  proves  of  permanent  benefit  in 
these  cases." 

Demosthene  made  281  operations  for  tubercular  disease, 
with  a  mortality  of  4  per  cent.;  the  immediate  results  are 
always  favorable ;  the  remote  results  are  as  yet  unknown. 
Bousquet  has  always  noted  a  material  improvement  of  the 
general  health  of  the  patients  subjected  to  surgical  treatment. 
Molliere,  Houzel,  and  Queirel  favor  operative  treatment  in  all 
proper  cases.  Routier,  after  giving  his  statistics,  expressed  him- 
self as  being  convinced  of  the  harmlessriess  and  utility  of  opera- 
tive procedures,  and  lias  always  noticed  that  the  general  health 
of  the  patients  improved  after  them.  Le  Dentu  is  in  favor  of 
surgical  treatment  and  claims  that  the  attacks  of  tubercular 
meningitis  which  occasionally  appear  to  be  provoked  by  opera- 
tions are  only  a  rare  coincidence.  Boeckel's  work  in  this  de- 
partment of  surgery  has  been  quite  extensive,  and  dates  back 
more  than  fourteen  years;  it  includes  53  amputations  and  151 
resections, — in  all  204  operations;  mortality,  8  per  cent,  after 
amputation  and  12  per  cent,  after  resection.  Of  16  deaths 
occurring  soon  after  operation,  9  were  from  tuberculosis;  of 
14  deaths  in  which  the  interval  between  the  operation  and 
fatal  termination  was  longer,  11  died  of  tuberculosis  and  the 
remainder  of  pneumonia  and  albuminuria.  Schwartz  gave  his 


IMMEDIATE    AND    REMOTE   RESULTS   OF   RESECTION.  319 

opinion,  based  on  200  operations  that  he  performed,  that  in 
all  but  one  the  immediate  effects  were  favorable;  in  this  case 
death  from  acute  pulmonary  tuberculosis  followed  a  short  time 
after  the  removal  of  a  tubercular  testicle.  Leonte,  in  his  68 
operations,  had  one  death  from  acute  miliary  tuberculosis  soon 
after  a  resection  of  a  tubercular  knee-joint.  In  reference  to  re- 
currence of  the  disease  after  operation  he  says :  "  The  relapse 
constitutes  a  rock  against  which  almost  inevitably  all  our  efforts 
are  broken  in  the  struggle  against  local  tuberculosis." 

Leroux's  thesis  (1879)  gives  an  account  of  twenty-four 
cases  whose  general  condition  was  aggravated  by  the  operation, 
and  Thiery  (ibid.,  p.  637)  adds  four  new  cases. 

At  the  Congress  of  French  Surgeons,  in  1889,  Le  Dentu 
reported  several  cases  of  multiple  tuberculosis  in  which  the 
operative  removal  of  the  primary  focus  resulted  in  disappearance 
of  the  remaining  lesions  and  a  permanent  cure.  Thiery  is  of 
the  opinion  that  the  removal  of  the  primary  depot  protects  the 
organism  against  ulterior  visceral  diseases,  of  which  the  periph- 
eral tuberculosis  would  have  been  the  point  of  departure. 

At  the  same  Congress,  Iscovesco  said  in  substance :  "  Hasty 
operative  intervention  cannot  be  justified  if  it  is  intended  for 
total  suppression  of  every  source  of  infection.  Besides,  the  fre- 
quency of  secondary  infection  is  certainly  exaggerated,  and 
successive  infections  are  wholly  ignored." 

Valude,  a  firm  supporter  of  surgical  treatment  of  peripheral 
tuberculosis,  maintained  that,  without  such  intervention,  the 
disease  would  become  general  in  the  majority  of  cases.  The 
remote  results  of  operative  interference  for  tubercular  affections 
are  more  gloomy  than  the  immediate  effects  of  the  operations, 
according  to  the  writings  of  Thiery  ("De  la  Tuberculose 
Chirurgicale,"  etc.  Paris,  1890,  p.  389  et  sequi)  and  his  quo- 
tations from  other  French  surgeons.  While  the  immediate 
results  following  the  surgical  intervention  in  local  or  localized 
tuberculosis  of  the  bones  and  joints  are,  speaking  from  an  oper- 
ative point  of  view,  generally  satisfactory,  the  remote  conse- 


320  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

quences  are  less  encouraging,  and  in  the  large  majority  of  cases 
but  few,  very  few,  patients  are  exempt  from  local  recurrence  or 
the  appearance  of  the  disease  in  other  parts  of  the  body.  Thiery 
has  traced  the  final  outcome  for  two  to  four  years  in  thirty-three 
cases  operated  on  for  b'one  or  joint  tuberculosis,  to  wit:  Bones 
of  extremities,  7;  mastoid,  2;  costo-sternal  articulations,  3; 
shoulder-joint,  1;  elbow,  4;  wrist,  1;  hip,  2;  knee,  1;  foot,  6; 
vertebrae,  4;  synovial  tuberculosis,  2.  In  15  additional  cases 
the  treatment  consisted  exclusively  of  the  internal  administra- 
tion of  drugs  and  other  measures  to  improve"  the  general  health. 
Of  these  48  cases  the  remote  results  were:  cured,  26  ;  improved, 
12;  stationary,  11;  local  aggravation,  2;  local  relapse,  26; 
relapse  a  distance,  13;  death  from  pulmonary  tuberculosis,  8. 
Verneuil  expressed  himself  on  this  point  as  follows:  "  Perma- 
nent favorable  results  are  rare.  The  tubercular  process,  checked 
for  a  time  by  the  operation,  is  very  prone  to  resume  its  course, 
and  patients  operated  on  for  tubercular  affections  never  reach 
old  age." 

Oilier  did  not  follow  his  thirty-two  cases  of  excision  of  the 
astragalus  long  enough  to  formulate  definite  conclusions  in  ref- 
erence to  the  permanent  value  of  the  operation.  Demosthene, 
Molliere,  Rentier,  and  Le  Dentu  speak  encouragingly  of  the 
remote  results  of  their  joint  resections  for  tuberculosis.  In  ref- 
erence to  amputations  as  a  curative  measure,  Boeckel  gives  his 
experience,  which  comprises  17  operations  done  for  tuberculosis 
of  the  large  joints,  of  which  16  recovered,  patients  remaining 
well,  at  the  time  the  report  was  made,  from  nine  to  fourteen 
years.  At  the  same  time  he  relates  127  resections,  including 
all  of  the  large  joints,  of  which  111  recovered  and  12  died, — a 
mortality  of  6  per  cent.  The  remote  results  of  these  are  inter- 
esting: 16  deaths  soon  after  operation,  of  which  9  occurred 
from  tuberculosis,  and  14  late  deaths,  of  which  11  could  be 
attributed  to  tuberculosis;  of  24  various  bone  resections  there 
were  15  permanent  recoveries  and  9  delayed  deaths.  He  be- 
lieves that  resection  is  a  less  dangerous  operation  than  ampu- 


IMMEDIATE    AND    REMOTE    RESULTS    OF    RESECTION.  321 

tation  in  the  treatment  of  tubercular  affections  of  the  extremi- 
ties. In  10  resections  of  the  knee,  made  by  Schwartz,  local 
recurrence,  calling  for  a  second  operation,  amputation,  or  grnt- 
tage,  occurred  three  times.  The  French  surgeons  are  almost 
unanimous  in  the  opinion  that  the  immediate  results  of  opera- 
tive interference  in  the  treatment  of  tubercular  affections  of 
bones  and  joints  are,  as  a  rule,  favorable,  but  that  the  prognosis 
in  regard  to  the  ultimate  benefit  of  resection  and  amputation  is 
not  equally  satisfactory.  Vargas,  of  Madrid,  is  opposed  to  the 
idea  that  the  operative  removal  of  tubercular  lesions  of  bones 
and  joints  is  ever  followed  by  traumatic  dissemination  or  any 
remote  ill  consequences.  He  is  of  the  opinion  that  such  at- 
tempts are  instrumental  not  only  in  bringing  about  a  local  cure, 
but  are  equally  efficient  in  protecting  the  organism  against  gen- 
eral infection.  In  support  of  these  assertions  he  cites  114  cases 
from  the  practice  of  Rivera,  Surgeon-in-Chief  of  the  Hospital 
of  the  Infant  Jesus,  and  200  cases  of  osseous,  articular,  and 
glandular  tuberculosis  of  Alabern,  who  found  tubercle  bacilli  in 
all  cases,  and  in  which  no  post-operative  lesions  developed, 
except  in  2  cases,  where  the  operation  was  deferred  too  long, 
and  in  5  cases  that  were  not  subjected  to  surgical  treatment. 

Korff  ("  Ueber  die  Endresultate  der  Gel  en  k  Resectionen." 
Deutsche  Zeitsclirift  f.  Chirurgie,  B.  xxii,  p.  149)  reports  the 
final  results  in  104  cases  of  resection,  of  mostly  the  larger 
joints,  with  a  mortality  of  39, — 34  of  tuberculosis, — and  of 
these,  in  7  the  resection  wound  had  already  been  healed.  In  3 
cases  that  died  of  tuberculosis  amputation  was  made  after  the 
resection  proved  a  failure.  The  American  surgeons,  as  a  whole, 
believe  in  the  curative  and  prophylactic  efficacy  of  operative 
treatment  of  tubercular  affections  of  bones  and  joints,  and  quite 
a  number  of  them  are  ardent  supporters  of  early  radical  treat- 
ment, notably  among  them  Mynter  ("  Is  Early  Resection  or 
Conservative  Treatment  Advisable  in  Coxitis  1 "  Journal  Ameri- 
can Medical  Association,  July  26,  1891).  This  surgeon  reports 
several  cases  where  he  made  resection  a  few  weeks  after  begin- 


21 


322  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

ning  of  the  joint-lesion,  found  well-marked  pathological  con- 
ditions, and  obtained  good  results.  One  of  the  gravest  objec- 
tions to  operative  treatment  of  tubercular  affections  of  bone 
and  joints  has  been  that,  at  least  in  rare  cases,  operations  of 
this  kind  have  been  followed,  within  a  few  days  to  a  few 
weeks,  by 

TRAUMATIC    DISSEMINATION   OF  THE  TUBERCULAR   PROCESS. 

By  this  expression  is  meant  re-infection  of  the  organism 
from  the  focus  disturbed  by  the  operation,  and  a  speedy  fatal 
termination,  resulting  from  acute,  general  miliary,  or  pulmonary 
tuberculosis,  or  tubercular  meningitis.  Konig  observed  sixteen 
cases  in  his  own  practice  in  which  miliary  tuberculosis  followed 
within  a  few  days  after  operations  on  bones  and  joints  for 
tubercular  affections.  He  states  that  the  secondary,  or  re-infec- 
tion, sets  in  seven  to  ten  days  after  operation,  which  may  have 
been  perfectly  aseptic,  with  healing  of  the  wound  by  primary 
union.  The  re-infection  caused  by  the  trauma  inflicted  by  the 
operation  appears  either  as  an  acute,  general  miliary,  or  pulmo- 
nary tuberculosis,  or  tubercular  meningitis,  terminating  in  death 
three  or  four  weeks  after  the  operation.  Rapid  generalization 
of  tuberculosis,  following  operations  destined  to  eradicate  or 
suppress  a  localized  tubercular  process,  has  been  repeatedly  ob- 
served. Demars  and  Verneuil  reported  a  number  of  such  cases ; 
but  no  one  can  foresee  or  anticipate  such  a  sequela  in  any 
patient  operated  upon.  This  complication  comes  sooner  in  one 
than  in  another.  Nothing  announces  the  impending  danger, — 
neither  the  variety  nor  the  local  progress,  nor  the  patient's  con- 
dition before  the  operation,  nor  the  extent  or  severity  of  the 
operation.  The  pathogenesis  of  these  cases  is  explained  by 
Verneuil  (fitndes  sur  la  tuberculose,  fascicule  i,  p.  238)  as 
follows :  "  When  we  operate  on  an  infected  focus,  be  it  osseous, 
articular,  serous  surface,  glandular,  etc.,  there  is  great  danger 
from  auto-infection  from  this  disturbed  local  hearth  ;  for  the 
imprisoned  microbes  in  the  loco  dolenti,  being  liberated  by  ths 


IMMEDIATE    AND    REMOTE   RESULTS   OF   RESECTION.  323 

traumatism,  may  enter  the  blood-current,  and  are  deposited  in 
various  organs,  as  the  lungs,  envelopes  of  brain,  serosa,  etc., 
where  they  form  secondary  depots,  more  or  less  numerous  and 
important."  While  this  auto-infection  is  certainly  possible,  this 
source  of  danger  has  been  greatly  overestimated,  for,  if  proper 
precautions  are  practiced,  it  is  certainly  one  of  the  rarest  wound 
complications  in  such  cases.  The  danger  arising  from  this 
source  is  greater  in  scraping  operations  on  bones  and  joints  than 
in  resection  or  amputation.  Cases  of  acute  pulmonary  tubercu- 
losis developing  shortly  after  operations  for  tubercular  affections 
have  been  reported  by  Demars,  Verneuil,  Verchere,  Metaxas,  and 
others.  Tliiery  {ibid.,  p.  175)  cites  a  number  of  illustrative 
cases.  Hygroma  praepatellaris  tuberculosa.  General  health 
very  good;  no  pulmonary  lesions.  Incision;  grattage.  Ten 
days  later,  haemoptysis ;  death  in  twenty-five  days.  Autopsy : 
"  Granulie  pulmonaire."  Old  coxitis  ;  "  redresscment,"  and 
immobilization  in  silicate  dressing.  Tubercular  meningitis  a 
few  days  later  takes  a  chronic  course.  Shortly  after,  general 
miliary  tuberculosis  and  death.  Tubercular  gonitis ;  no  pul- 
monary tuberculosis  ;  redressement.  Within  a  few  days,  acute 
pulmonary  and  general  tuberculosis  (Szuman).  Tibio-tarsal 
tubercular  arthritis.  Tubercular  meningitis  on  sixth  day  after 
operation,  and  death  on  the  seventh.  Old  and  recent  pulmo- 
nary tuberculosis  (Socin  and  Keser,  Jahresbericht  uber  die 
Chir.  Abtheilung  zu  Basel,  1884,  p.  136).  Daremberg  studied 
the  susceptibility  of  the  meninges  of  the  brain  to  tubercular 
infection  experimentally  ("  Notes  sur  la  Meningite  tubercu- 
leuse  experimentale."  fitude  sur  la  tuberculose,  p.  530).  He 
ascertained  that  death  was  regularly  produced  in  rabbits  in  from 
twenty-one  to  thirty  days,  from  tubercular  meningitis,  after 
direct  inoculation  with  tubercular  material.  The  symptoms 
resembled  those  which  characterize  the  disease  in  man, — paraly- 
sis, general  hemiplegia,  loss  of  vision  and  hearing,  acute  cries 
upon  slightest  disturbance.  The  pathological  changes  in  the 
meninges  resembled  closely  those  found  in  the  cadaver  of  per- 


324  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

sons  who  succumbed  to  this  disease.  While  the  liver  of  these 
animals  presented  no  macroscopical  tubercular  lesions,  numer- 
ous bacilli  were  found  in  that  organ  by  the  aid  of  the  micro- 
scope. Guinea-pigs  inoculated  in  the  same  manner  also  died 
in  from  twenty-one  to  thirty  days,  from  acute  tuberculosis ;  but 
the  meninges  of  the  brain  showed  no  signs  of  disease.  It 
appears  from  this  that  in  these  animals  no  localization  occurred 
in  the  meninges,  the  disease  assuming,  from  the  beginning,  a 
diffuse  form.  These  experiments  demonstrate  that  infection 
of  the  meninges  of  the  brain  is  almost  sure  to  give  rise  to  dif- 
fuse tuberculosis,  provided  the  animal's  life  is  sufficiently  pro- 
longed. A  chicken  and  pigeon,  inoculated  in  the  same  way, 
through  a  small  opening  in  the  skull,  died  in  six  and  seven 
months,  from  tubercular  meningitis,  and  the  autopsy  showed,  at 
the  same  time,  tubercles  in  the  liver, — a  proof  that  in  these  ani- 
mals a  longer  time  was  required  to  produce  the  disease  arti- 
ficially than  in  rabbits  and  guinea-pigs.  That  meningitis  may 
occur  after  an  accidental  or  intentional  trauma  in  a  tubercular 
individual  has  been  known  for  a  long  time,  and  the  laity  even 
understand  the  possibility  of  this  source  of  danger  following- 
violence  in  children.  Many  a  sorrowing  mother  has  attributed 
the  fatal  disease  to  a  fall  or  blow  upon  the  head. 

This  subject  was  thoroughly  discussed,  from  a  scientific 
surgical  stand-point,  in  the  Societe  de  Chirurgie,  in  1883,  by 
Verneuil,  Trelat,  Berger,  Richelot,  Despres.  and  others,  and  it 
was  admitted  on  all  sides  that  tubercular  meningitis  could  de- 
velop after  the  slightest  surgical  intervention  in  the  treatment 
of  tubercular  affections ;  but  the  question  whether  this  complica- 
tion is  a  mere  coincidence  or  the  result  of  operation  was  not 
then,  and  has  not  since  been,  definitely  settled.  In  some  cases 
the  cerebral  affection  appears  already  within  the  first  twenty- 
four  hours  after  the  operation,  the  prominent  symptoms  being  a 
chill,  high  temperature,  headache,  and  obstinate  vomiting;  but 
in  the  majority  of  cases  the  patient  progresses  favorably  for  ten 
or  twenty-five  days,  and  then,  without  premonition,  the  brain 


IMMEDIATE    AND    REMOTE   RESULTS   OP   RESECTION.  325 

symptoms  appear,  while  in  a  relatively  small  number  of  patients 
the  meningeal  complication  is  more  remote.  One,  two,  or  more 
months  may  pass  by,  the  wound  in  the  meantime  having  com- 
pletely healed,  when  suddenly  these  late  meningeal  symptoms 
appear,  and  life  is  destroyed  in  a  few  days  from  this  cause  alone. 
The  autopsy  reveals  a  diffuse  recent  meningitis,  for  which  no 
other  cause  but  the  primary  focus  for  which  the  operation  was 
made  can  be  found.  The  blood-vessels  and  lymphatics  along 
the  chiasma  and  the  envelopes  at  the  base  of  the  brain  are 
studded  with  young  granulations,  radiating  irregularly  or  in 
disseminated  groups  in  the  fissure  of  Sylvius.  Chantemesse 
has  observed  heaps  of  granulations  in  patches  in  adults,  and 
Metaxas  and  Verchere  (fitude  sur  la  hiberculose,  page  535  et 
seq.}  have  more  rarely  observed  thickened  pia  matter  with  puru- 
lent appearance,  rarely  due  to  softened  tubercles,  as  described 
and  found  in  cases  of  tubercular  meningitis  in  children.  These 
anatomical  lesions,  so  acute,  numerous,  and  diffuse,  point  directly 
to  the  true  source  and  nature  of  the  determining  cause.  It  is 
not  essential  that  the  operation  should  have  been  made  on  a 
tubercular  focus  in  the  causation  of  a  traumatic  tubercular  men- 
ingitis, as  this  lesion  may  develop  in  a  tubercular  subject  after 
a  fall  on  the  head,  a  blow,  a  contusion;  but,  as  a  rule,  it  develops 
as  a  post-operationem  result. 

Chantemesse  {These  de  Pan's,  p.  165,  Obs.  46)  has  found, 
as  one  of  the  conditions  of  traumatic  tubercular  meningitis,  the 
remains  of  a  similar  lesion,  from  which  the  patient  had  recovered 
completely  years  before  the  appearance  of  the  second  attack, — 
due  to  traumatism  or  surgical  intervention  for  other  tubercular 
lesions.  Therefore,  post-operative  meningitis  may  be  a  primary 
lesion  in  an  otherwise  healthy  person,  but  predisposed  to  tuber- 
culosis from  hereditary  or  acquired  infection  ;  it  more  frequently 
occurs  in  the  tubercular  with  manifest  visceral  or  peripheral 
lesions.  Of  these  the  latent  meningeal  localizations  are  the  most 
dangerous  and  cause  a  second  acute  attack  most  rapidly.  The 
disease  is  most  prone  to  follow  operations  on  tubercular  bones 


326  TUBERCULOSIS   OP   THE   BONES   AND   JOINTS. 

or  joints,  and  scraping  of  tubercular  affections  of  the  soft  parts. 
Pathological  anatomy  has  shown  that  the  meningitis  is  recent, 
and  that  the  lesions  present  appearances  which  do  not  date 
farther  back  than  the  operation.  Serous  surfaces,  and  among 
them  the  meninges  of  the  brain,  are  favorite  localities  in  which 
tubercle  bacilli  that  have  entered  the  general  circulation  become 
localized,  and  in  which  they  exercise  their  specific  pathogenic 
properties.  During  an  operation  Tor  tuberculosis  some  of  the 
bacilli  may  find  their  way  into  the  blood-current,  and,  if  they 
accumulate  in  the  envelopes  of  the  brain  in  sufficient  number, 
they  give  rise  to  secondary  disease  in  these  structures. 

Metaxas  and  Verchere  have  collected  55  cases  of  menin- 
gitis following  operations,  with  the  following  result:  Resection, 
18  times;  amputation,  6;  grattage  of  abscesses  or  fungosities, 
11;  tuberculosis  of  spine,  3;  evidements  for  tuberculosis  in 
other  localities,  2  ;  incomplete  removal  of  tubercular  testicle,  2 ; 
extirpation  of  tubercular  glands,  3.  In  2  cases  the  disease 
followed  ignipuncture  of  tubercular  joints,  and  once  it  could  be 
traced  to  debridement  of  the  nasal  cavity.  These  authors  claim 
that  more  than  half  of  the  cases  of  tubercular  meningitis  are 
caused  by  operations  for  tubercular  disease  of  bone,  and  they 
conclude  their  valuable  paper  on  this  subject  by  placing  on 
record  the  following  cases: — 

Case  I.  Boy  14  years  old ;  coxitis.  Resection.  Perforation 
acetabulum.  Death  from  tubercular  meningitis  seven  months 
later.  A  few  tubercles  in  lung,  liver,  and  spleen. 

Case  II.  Boy  2  years  old;  abscess  behind  left  trochanter 
major.  Excision  of  hip-joint;  joint  very  extensively  affected. 
Death  from  tubercular  meningitis  sixty-six  days  after  operation. 

Case  III.  Boy  7^  years  old ;  disease  of  left  hip-joint ;  gen- 
eral condition  precarious.  Resection  of  joint  with  five  centimetres 
of  the  shaft  of  femur ;  the  latter  was  done  for  suppurative  osteo- 
myelitis whicli  affected  this  portion  of  the  bone.  Death  fifty- 
three  days  after  operation  from  tubercular  meningitis,  as  was 
confirmed  by  the  autopsy. 


IMMEDIATE  AND  REMOTE  RESULTS  OF  RESECTION.         327 

Case  IV.  Girl  aged  5  years;  coxitis  left  side  and  perfora- 
tion of  cotyloid  cavity.  Resection.  Death  from  basilar  menin- 
gitis fifty-three  days  after  operation. 

Case  V.  Young  man  with  hereditary  history.  Injury  of 
knee  and  forearm;  arm  amputated  about  through  the  middle. 
Diagnosis  of  tubercular  meningitis  made  fifty-three  days  after 
operation ;  death  two  days  later.  Autopsy :  Acute  basilar  men- 
ingitis with  acute  hydrocephalus,  also  acute  miliary  tuberculosis 
of  lung. 

Case  VI.  Man  32  year  old,  received  an  injury  of  the  knee 
which  made  an  amputation  of  the  thigh  necessary  about  one 
year  and  three  quarters  later;  tubercular  meningitis  two  days 
later,  and  death  one  day  later.  Autopsy:  Recent  basilar  men- 
ingitis, miliary  tuberculosis  of  lungs  and  peritoneum,  also 
tubercular  ulcer  of  intestine. 

Case  VII.  Boy  9  years  old,  with  fungous  arthritis  of  knee- 
joint  of  three  years'  duration.  Resection.  Death  thirty-nine 
days  after  operation,  from  tubercular  meningitis.  Autopsy: 
Tubercles  at  base  of  brain,  in  the  lungs,  spleen,  liver,  and 
kidneys;  no  caseous  foci. 

Case  VIII.  Child  3  years  old;  tuberculosis  of  calcaneus 
with  fistula3.  Scraping  out  of  diseased  bone  and  injection  with 
chloride-of-zinc  solution.  Death  seven  months  later,  preceded  by 
cerebral  symptoms  and  incipient  pulmonary  phthisis.  Autopsy: 
Bilateral  caseous  nodules  in  cerebellum  the  size  of  an  apple; 
tuberculosis  of  lung,  mesenteric  glands,  and  intestines. 

Case  IX.  Man  aged  23,  with  a  white  swelling  of  knee  of 
several  years'  duration.  Resection  of  joint.  Death  six  weeks 
later,  from  tubercular  meningitis. 

Case  X.  Boy  7  years  old.  Arthritis  of  knee-joint  of  several 
years'  duration.  Resection.  Death  sixty-eight  days  later,  from 
tubercular  meningitis. 

Case  XL  Esmarch  lost  a  little  patient  from  tubercular 
meningitis  sixteen  days  after  resection  of  a  tubercular  wrist- 
joint. 


328  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

Case  XII.  Girl  3^  years  old,  suffering  from  tubercular 
coxitis  for  one  year.  Resection  of  head  of  femur  and  scraping 
of  acetabulum.  Death  thirty-nine  days  afterward,  from  tuber- 
cular meningitis. 

Case  XIII.  Child  aged  1 1  years,  with  white  swelling  of 
knee  for  three  months.  Resection.  Death  a  week  after  operation, 
from  diarrhoea  and  convulsions. 

Case  XIV.  Tibio-tarsal  arthritis.  Resection.  Tubercular 
meningitis  six  days  later,  and  death  the  following  day.  Old 
and  recent  pulmonary  tuberculosis.  ("  Socin  and  Keser,"  p.  136. 
Basel,  1884.) 

Case  XV.  Amputation  of  the  leg  through  upper  third  for 
tibio-tarsal  arthritis,  in  a  young  boy.  Healing  by  first  intention 
during  the  second  week.  Death  from  tubercular  meningitis  and 
acute  miliary  tuberculosis  of  lung,  twenty-seven  days  after 
operation. 

Case  XVI.  Child  6  years  old.  Tibio-tarsal  tuberculosis 
with  deep  seated  osseous  foci.  Ignipuncture  in  ten  different 
places.  No  indications  of  pulmonary  or  meningeal  tuberculosis 
until  twelve  days  after  cauterization  of  the  interior  of  the  joint, 
when  a  tubercular  meningitis  set  in  and  proved  fatal  in  thirteen 
days.  Diagnosis  confirmed  by  the  autopsy. 

Case  XVII.  Child  6  years  old,  convalescent  from  an  attack 
of  measles,  was  kicked  on  the  left  fronto-parietal  region,  causing 
ecchymosis  and  swelling,  and  ten  days  later  headache,  vomiting, 
and  fever.  In  sixteen  days  death  from  tubercular  meningitis. 
(Ozenne,  Bull.  Medicale,  1887,  p.  524.) 

Case  XVIII.  Boy  7  years  old,  suffering  from  otitis  media 
for  several  months.  Mother,  brother,  and  several  sisters  died 
of  phthisis.  Contusion  of  head,  caused  by  striking  against  wall, 
is  followed  by  malaise  and  headache,  lasting  ten  days,  then 
found  unconscious.  When  admitted  to  hospital,  two  days 
later,  the  following  symptoms:  Unconsciousness;  pupils  equal, 
react  to  light;  respiration  easy,  but  shallow;  small,  irregular 
pulse;  lips  and  tongue  coated;  abdomen  very  contracted;  ex- 


IMMEDIATE    AND    REMOTE    RESULTS   OF    RESECTION.  329 

tremities  rigid;  continued  nearly  in  same  condition  until  death, 
twelve  days  later;  cerebral  convolutions  flattened;  disseminated 
tubercles  at  base  of  brain,  near  the  fissure  of  Sylvius,  with  very 
marked  evidences  of  meningitis  ;  considerable  fluid  in  ventricles, 
and  dilatation  of  the  foramen  of  Monro ;  lungs  studded  with 
recent  tubercles,  especially  in  the  apices ;  caseous  foci  in  the 
renal  pyramids,  with  some  pyelitis. 

In  addition  to  these  cases  the  same  authors  report  three 
cases  in  which  the  cerebral  affection  made  its  appearance  more 
remotely  from  the  time  of  operation,  but  in  which  the  secondary 
infection,  from  the  absence  of  caseous  foci  in  other  organs,  had 
to  be  connected  with  the  primary  lesion  subjected  to  operative 
interference.  "Thiery  cites  a  number  of  cases  of  tubercular  men- 
ingitis following  operative  treatment  of  tubercular  affections: — 

Case  I.  Volkmann.  Coxitis  on  right  side.  Ignipuncture 
and  radage  May  1,  1874.  Meningitis  and  death  August,  same 
year.  Autopsy  reveals  tubercular  meningitis,  and  acute  tuber- 
culosis of  liver,  lungs,  and  spleen. 

.  Case  II.  Wahl.  Chronic  abscess  behind  left  trochanteric 
region.  Resection.  Sixty-six  days  after  operation,  death  from 
tubercular  meningitis. 

Case  III.  Wahl.  Left  coxitis  with  multiple  abscesses.  Re- 
section. Fifty-three  days  after  operation,  death  from  tubercular 
meningitis. 

Case  IV.  Volkmann.  Left  coxitis  and  iliac  abscess. 
Resection  March  11,  1873.  Basilar  meningitis  April  28th,  and 
death  May  3d. 

Case  V.  Konig.  Fungous  arthritis  of  knee.  Resection 
November  18,  1869,  and  death  from  tubercular  meningitis 
December  27th. 

Case  VI.  Sayre.  White^  swelling  of  knee.  Resection. 
Tubercular  meningitis,  and  death  six  weeks  later. 

Case  VII.  Billroth.  Chronic  inflammation  of  knee-joint. 
Resection  May  1,  1860.  Tubercular  meningitis,  and  death 
July  7th. 


330  TUBERCULOSIS   OP  THE   BONES  AND   JOINTS. 

Case  VIII.   Hinsch.     Esmarch's  case,  previously  quoted. 

Case  IX.  Coxo-femoval  caries.  Resection  on  thirty-ninth 
day  ;  death  from  tubercular  meningitis. 

Case  X.  White  swelling  of  knee-joint.  Resection.  Death 
eight  days  later,  preceded  by  diarrhoea  and  convulsions  (child 
1^  years  old). 

Case  XI.  Fall  on  head.  Death  from  tubercular  meningitis 
(previously  cited). 

I  could  add  several  cases  of  tubercular  meningitis  and  dif- 
fuse miliary  tuberculosis  following  operative  procedures  from 
my  own  experience,  but  enough  cases  have  been  quoted  to  show 
that  the  danger  from  this  source  is  real,  and  not  imaginary, 
and  should  always  be  borne  in  mind  in  performing  operations 
for  tubercular  lesions  with  a  view  toward  preventing  traumatic 
dissemination,  It  is  not  difficult  to  conceive  the  modus  operandl 
of  the  occurrence  of  re-infection  during  and  shortly  after  opera- 
tions for  tubercular  aifections,  more  especially  if  the  operation 
is  incomplete.  The  scraping,  resection,  or  amputation  wound 
opens  numerous  veins  in  the  bone,  the  lumina  of  which  remain 
patent,  ready  for  the  introduction  of  minute  fragments  of  granu- 
lation tissue  or  free  bacilli,  which,  on  entering  the  general  circu- 
lation, are  the  direct  cause  of  metastatic  tuberculosis  in  distant 
organs.  We  must  take  it  for  granted,  in  such  cases,  that  a 
tubercular  focus,  during  the  operation,  furnished  the  essential 
cause  of  the  distant  lesions, — infected  fragments  of  granulation 
tissue  or  free  bacilli,  which  are  aspirated  or  pushed  into  the 
openings  of  the  wounded  vessels,  and  through  them  gain 
entrance  into  the  general  circulation.  Statistics  prove  only  too 
plainly  that  re-infection  is  most  likely  to  take  place  when  the 
operation  is  imperfectly  done,  and  is,  therefore,  more  frequently 
incurred  by  scraping  than  complete  eradication  of  the  primary 
focus  by  excision.  To  guard  against  such  an  accident,  in  oper- 
ating upon  tubercular  joints,  it  is  necessary  to  remove  from  the 
joint  all  possible  source  of  infection  before  the  atypical  or  typi- 
cal resection  is  made.  The  infected  soft  structures  of  the  joint 


IMMEDIATE   AND   REMOTE   RESULTS   OF   RESECTION.  331 

and  loosened  cartilage  should  be  carefully  removed  and  the 
surfaces  disinfected  before  the  chisel  or  saw  is  used ;  in  other 
words,  a  typical  arthrectomy  should  precede  the  resection. 
Cartilage  that  remains  firmly  attached  to  the  bone  may  be  left. 
After  all  foci  in  the  articular  ends  of  the  bone  have  been  radi- 
cally eliminated,  the  field  of  operation  is  again  flushed  with  a 
strong  aqueous  solution  of  iodine,  and,  after  drying  and  iodo- 
formization,  the  bone-cavities,  if  such  exist,  are  packed  with 
decalcified,  antiseptic  bone-chips,  when  the  operation  is  completed 
in  the  same  manner  as  in  arthrectomy. 


CHAPTER  XXIX. 

AMPUTATION. 

AMPUTATION  of  a  limb  on  the  proximal  side  of  a  tubercular 
joint  must  be  regarded  as  the  most  radical  treatment  of  the 
local  lesion,  and  as  affording  most  efficient  protection  against  re- 
infection of  the  body  from  this  source.  Although  amputation 
has  become  more  and  more  restricted  as  other  less  mutilating 
operations  are  being  made  safer  and  more  efficient  in  the  treat- 
ment of  tubercular  affections  of  the  extremities,  it  will  always 
hold  a  legitimate  place  in  the  treatment  of  grave  cases  beyond 
the  reach  of  less  heroic  measures.  Although  Benjamin  C.  Bell 
("Diseases  of  Joints,"  p.  150.  London,  1850)  had  no  concep- 
tion of  the  true  nature  of  tubercular  disease  of  joints,  his  reason- 
ing in  favor  of  complete  removal  of  the  peripheral  local  disease 
by  amputation,  in  appropriate  cases,  must  be  considered  as 
logical  and  correct  at  the  present  day.  "  It  is  to  be  observed 
that  this  disease  of  a  joint  is  very  rarely  more  than  the  remote 
cause  of  death,  and  that,  when  the  result  is  fatal,  it  almost  in- 
variably happens  in  the  following  manner:  The  patient  is 
exhausted  by  hectic  fever,  and  in  this  state  of  debility  disease 
takes  place  in  the  mesentery  or  lungs,  or,  not  un frequently,  in 
both  these  parts  at  the  same  time,  and  it  is  this  visceral  affection 
which  immediately  precedes  dissolution.  It  is  evident,  then, 
that  in  many  cases  there  is  a  period  of  time  at  which  the  ampu- 
tation of  the  limb  may  be  the  means  of  preventing  the  establish- 
ment of  a  secondary  disease.  Nor  is  this  all ;  visceral  disease, 
which  was  previously  in  a  state  of  inactivity,  may  assume  a  new 
form  and  begin  to  make  a  rapid  progress  under  the  depressing 
influence  of  the  disease  of  the  joint.  Amputation  under  these 
circumstances  may  be  the  means  of  preserving  the  patient,  if  not 
altogether,  at  least  for  a  considerable,  length  of  time, — perhaps 
for  several  years." 

Oilier  ("  Des  Operations  conservatrices  dans  la  tuberculose 
(332) 


AMPUTATION.  333 

articulaire."  Copenhagen  International  Medical  Congress,  1884) 
has  well  said  that  amputation  is  undoubtedly  that  operation 
which  furnishes  the  greatest  safety  against  infection  from  the 
local  disease  in  the  bones  or  joints,  but  it  cannot  be  regarded  as 
a  radical  operation  because  deep-seated  and  inaccessible  lym- 
phatic glands  are  left  behind,  which  in  old  cases  are  always  more 
or  less  affected.  Amputation  is  especially  indicated  in  osteo- 
arthritis  of  the  lower  extremities,  as  it  is  important  to  remove 
the  patient  as  soon  as  possible  from  the  debilitating  influences 
of  prolonged  confinement  in  bed. 

Pilcher  ("  Notes  on  Amputation  for  Joint  Disease  when 
Lung  Tuberculosis  Co-exists."  Annals  of  Surgery ',  vol.  v,  p. 
101)  has  again  called  attention  to  the  value  of  amputation 
as  a  surgical  resource  in  the  treatment  of  tubercular  joints 
complicated  by  pulmonary  phthisis.  He  urges  this  opera- 
tion particularly  in  the  case  of  adults,  in  which  other  less 
heroic  measures  hold  out  less  encouragement  than  in  chil- 
dren. He  maintains  that  amputation  wounds  in  such  cases 
heal  as  promptly  as  when  amputation  is  done  for  other  indi- 
cations, and  that  very  often  patients  reduced  to  a  skeleton 
under  the  combined  influence  of  several  wasting  diseases  re- 
cover flesh  and  health  after  the  removal  of  the  peripheral  lesion 
by  amputation. 

Thiery  (loc.  tit.,  pp.  451  and  452)  has  made  a  study  of 
ninety-four  cases  of  tuberculosis  of  the  extremities  to  ascertain 
the  comparative  merits  of  amputation  and  resection : — 

Amputation.  Resection. 

Deaths 27  Deaths, 36 

Complete  recovery,  .     .     12  Complete  recovery,  .     .      9 

Incomplete  recovery,     .      5  Incomplete  recovery,     .      5 

44  ~50 

In  this  connection  Boeckel's  material,  consisting  of  204 
cases,  covering  a  period  of  fourteen  years, — 1875  to  1888  inclu- 
sive,— is  of  great  value.  It  embraces  53  amputations  and  151 
resections ;  of  the  latter,  27  resections  of  large  joints  and  24  re- 


334  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

sections  of  bones  of  the  trunk.  Resections  of  small  joints  and 
les  evidements  osseux  are  not  included  in  this  list.  Amputa- 
tions: The  53  cases  furnished  en  bloc  49  recoveries  and  4 
deaths.  Fourteen  have  been  lost  sight  of  since  leaving-  the 
hospital ;  the  others  were  heard  from  later.  They  are  described 
as  follows:  Thigh,  17  cases,  with  1  death  six  weeks  after 
operation,  from  a  heart  affection  in  the  case  of  a  woman  70 
years  old.  Two  others  died  two  months  after  amputation, — 
one  of  phlebitis  and  the  other  of  osteomyelitis ;  2  died  two 
and  three  years  after  amputation, — one  of  pneumonia  and 
the  other  of  cerebral  haemorrhage ;  1 2  are  alive  and  in  good 
health, — seven,  twelve,  and  fourteen  years;  the  oldest  of  these 
survivors  had,  at  the  time  the  report  was  made,  attained  the 
age  of  80  years.  Mortality  5.8  per  cent. ;  no  deaths  from 
tuberculosis. 

Leg  and  Arm. — Twenty-two  cases  with  19  recoveries  and 
3  deaths.  One  died  in  five  weeks  from  pulmonary  phthisis ; 
another  in  three  weeks,  from  Jicemopli/sie  foudroyante,  after 
amputation  of  leg ;  the  third  died  from  exhaustion  forty-eight 
hours  after  amputation  of  arm.  Of  the  19  recoveries,  5  were 
lost  sight  of  after  three  years;  of  the  remaining  14,  only 
10  are  alive  after  two,  three,  five,  eight,  nine,  ten,  eleven 
years,  and  in  good  health.  The  other  4  survived  eighteen 
months,  then  died  of  pulmonary  phthisis ;  five  years,  same 
cause  of  death ;  eight  years,  marasmus.  Lastly,  a  woman  of 
64  years,  arm  amputated,  was  in  good  health  for  six  years ; 
then  a  tubercular  osteo-arthritis  necessitated  amputation  of 
the  thigh,  which  she  survived  two  years,  finally  dying  of  albu- 
minuria. 

Of  the  39  patients  who  survived  the  operation  for  several 
years,  only  22  were  alive  at  the  time  the  report  was  made.  Of 
this  number  it  is  said  that  2  or  3  had  pulmonary  tuberculosis ; 
one  had  attacks  of  haemoptysis  for  two  years,  and  another  was 
the  subject  of  "  cavernules."  Resections  of  joints  are  classified 
thus : — 


AMPUTATION.  335 

Cases.  Recovered.       Death.  Mortality. 

Shoulder,     ...      6  6                   0  0 

Elbow,    ....     12  11                  1  8.3  per  cent. 

Wrist,     ....      2  2                   0  0. 

Hip, 32  20                 12  37.5 

Knee,       ....     58  55                   3  5.1 

Foot _17  JL7  _0  0. 

Total,    ...  127  111                16  12.6       " 

A  subject  of  some  interest,  in  connection  with  amputation 
for  tubercular  affections,  is  the  fact  that  sometimes  tubercular 
ulceration  may  appear  in  the  stump  after  amputation,  although 
the  previous  disease  for  which  the  operation  was  made  may  not 
have  been  tubercular  in  its  nature,  or  when  amputation  is  made 
through  perfectly  healthy  tissue  for  tubercular  lesions.  Verneuil 
described  this  condition  some  years  ago  as  he  observed  it  in  a 
case  which,  condensed,  is  as  follows :  A  boy  from  the  country, 
15  years  old,  in  apparently  good  health,  was  the  subject  of  an 
articular  and  tendinous  synovitis,  which  finally  made  an  ampu- 
tation necessary.  Union  of  wound  by  primary  intention,  except 
at  a  point  occupied  by  the  inner  drainage-tube,  where  a  small 
ulcer  formed.  This  ulcer  was  very  superficial,  but  gradually 
increased  in  size.  In  the  granulations  of  this  ulcer  Nepveu 
demonstrated  the  existence  of  giant-cells  and  tubercle  bacilli. 
The  usual  applications  proved  useless  in  arresting  the  destruc- 
tive process,  which  was  only  accomplished  by  deep  cauterization 
with  the  actual  cautery.  Verneuil  remarks,  in  commenting  on 
this  case,  that  two  hypotheses  might  be  advanced  to  explain  the 
causation  of  the  ulcer.  Either  the  tissues  at  the  site  of  ampu- 
tation were  infected  with  tubercle  bacilli,  or  the  wound  was 
infected  during  the  operation ;  but  he  felt  sure  that  the  tissues 
of  the  amputation  wound  were  perfectly  healthy  at  the  time  the 
operation  was  made,  and  is  inclined  to  the  belief  that  infection 
was  brought  about  by  the  localization  of  microbes  in  the  wound 
(auto-infection),  or  by  their  introduction  from  without  (traumatic 
infection).  Traumatic  infection  of  an  amputation  wound,  when 
the  operation  is  performed  for  the  removal  of  open  tubercular 
lesions,  should  be  prevented  by  covering  the  ulcerated  surface 


336  TUBERCULOSIS   OF   THE   BONES    AND    JOINTS. 

during  the  operation  and  by  careful  disinfection  of  the  whole 
limb.  In  the  treatment  of  tubercular  affections  of  the  extrem- 
ities amputation  must  be  reserved  for  cases  presenting  special 
indications.  It  is  the  only  operation  that  promises  any  benefit 
if  the  patient  suffer  at  the  same  time  from  tuberculosis  of  other 
organs,  provided  the  general  conditions  furnish  no  positive  con- 
tra-indications.  It  is  also  indicated  if  a  tubercular  abscess  has 
perforated  the  capsule  of  a  joint  and  has  extensively  infiltrated 
the  surrounding  tissues.  This  condition  is  to  be  expected  if  the 
limb  has  become  cedematous  some  distance  from  the  joint. 
Pronounced  anaemia  should  influence  surgeons  to  lean  toward 
amputation  rather  than  resection  in  tuberculosis  of  the  large 
joints.  It  is  absolutely  necessary  to  use  healthy  tissue  for  the 
flaps.  (Edematous  skin,  or  skin  riddled  with  fistulous  tracts, 
must  be  carefully  avoided.  The  flaps  must  be  taken  from  the 
side  of  the  limb  where  the  skin  is  in  the  best  condition,  and  the 
incision  through  the  deeper  parts  must  fall  through  healthy 
tissue.  Esmarch's  bandage  should  never  be  employed  in  oper- 
ating for  tubercular  affections,  as  its  use  might  bring  about 
infection  of  previously  healthy  tissues.  The  limb  should  be 
rendered  bloodless  by  elevation  of  limb  and  elastic  constriction 
some  distance  above  the  site  of  operation.  It  is- astonishing 
how  rapidly  wounds  heal  and  how  quickly  patients  will  recover 
after  amputations  for  extensive  local  tubercular  processes,  even 
when  greatly  emaciated  by  the  disease. 


CHAPTER  XXX. 

POST-OPERATIVE  TREATMENT. 

As  the  eradication  of  a  local  lesion  by  operative  measures 
seldom,  if  ever,  succeeds  in  eliminating  from  the  organism  all 
sources  of  infection,  the  local  should  always  be  combined  with 
general  treatment.  As  the  general  treatment  has  been  discussed 
elsewhere,  it  is  necessary  here  only  to  refer  again  to  the  impor- 
tance of  carrying  it  out  faithfully  and  persistently  after  all  opera- 
tions for  tubercular  affections,  in  order  to  so  improve  the  general 
health  that  remaining  sources  of  infection  may  become  harmless 
after  the  removal  of  the  principal  peripheral  focus  from  which 
re-infection  did  or  might  take  place.  The  knife,  saw,  sharp 
spoon,  and  Paquelin  cautery  must  be  preceded  and  followed  by 
efficient,  well-conducted  general  treatment.  The  surgeon  must 
be  a  physician  as  well  as  a  surgeon  in  the  successful  treatment 
of  such  cases.  The  use  of  guaiacol,  as  advised  by  Schueller, 
should  be  continued  for  three  months  to  a  year  after  operation, 
in  doses  of  2  to  5  drops  three  or  four  times  a  day,  according  to 
the  age  of  the  patient.  If  more  attention  were  given  to  appro- 
priate after-treatment  than  has  usually  been  the  case  in  the 
hands  of  most  surgeons,  statistics  of  operative  results,  both  im- 
mediate and  remote,  would  present  a  less  gloomy  aspect.  Im- 
provement of  the  general  health  of  tubercular  patients  by  general 
treatment  is  but  calculated  to  secure  a  satisfactory  process  of 
repair  after  operative  interference,  and  affords  the  most  efficient 
protection  against  local  recurrence  and  general  dissemination. 
In  order  to  secure  the  best  results  it  is  necessary  for  the  surgeon 
to  prepare  patients  properly  for  the  unavoidable  operative  treat- 
ment, which  may  require  weeks  or  months,  and  to  conduct  the 
necessary  after-treatment  not  only  until  the  wound  has  healed, 
but  until  the  patient  has  regained  his  usual  health.  Sunlight, 
out-door  air,  and  a  nutritious  diet  are  the  best  tonics  in  the 
building  up  of  tubercular  patients.  A  change  of  climate  is 

22  (337) 


338  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

often  productive  of  marked  improvement  in  patients  that  have 
recovered  from  the  immediate  effects  of  an  operation.  Dressings 
should  be  changed  as  infrequently  as  possible,  as  each  change 
is  attended  by  some  risk  of  infection  as  long  as  the  external 
wound  is  not  healed  completely.  Physical  and  psychical  rest  is 
an  essential  condition  in  procuring  a  satisfactory  wound-healing 
after  operations  for  tubercular  affections.  Physical  rest  is  secured 
by  proper  mechanical  support  of  the  part  or  limb  operated  on, 
by  position  and  fixation  dressings,  while  psychical  rest  is  ob- 
tained by  the  avoidance  of  unnecessary  pain,  and  by  careful 
attention  to  the  surroundings  of  the  patient.  Local  relapse 
must  be  suspected  if  the  wound  show  no  tendency  to  heal  and 
become  covered  in  a  few  days  by  profuse,  soft,  almost  gelatin- 
ous granulations,  or  if  the  wound  has  healed  by  the  character- 
istic appearance  of  the  cicatrix.  The  cicatrix,  instead  of  under- 
going atrophy  and  becoming  paler  from  day  to  day,  presents  a 
swollen,  cedematous,  and  livid  appearance.  In  a  short  time  the 
epidermis  is  destroyed,  the  whole  cicatrix  melts  away,  and  its 
place  is  taken  by  pale,  fungous  granulations,  which  manifest  no 
reparative  tendencies.  A  local  relapse  calls  for  prompt  opera- 
tive interference.  The  granulations  should  be  removed  thor- 
oughly with  a  sharp  spoon, — a  procedure  which  often  makes  it 
necessary  to  reopen  the  operation  wound  in  order  to  reach  all 
of  the  infected  tissues.  Such  an  operation  requires  all  the  anti- 
septic precautions  as  the  first  operation,  because  tubercular 
wounds  are  exceedingly  susceptible  to  infection  with  pus- 
microbes.  The  scraping  is  to  be  continued  until  firm,  healthy 
tissue  is  reached.  -The  wound  is  now  irrigated  with  strong 
iodine-water,  dried,  iodoformized,  and,  if  large,  partially  sutured. 
An  iodoform-gauze  tampon  should  be  used  and  allowed  to  re- 
main for  at  least  five  days.  The  part  is  dressed  in  the  same 
manner  as  after  the  first  operation.  Sometimes  the  operation 
wound  heals  in  a  satisfactory  manner  with  the  exception  of  one 
or  more  fistulous  tracts.  These  should  be  scraped  out  thorougly 
under  strict  antiseptic  precautions,  and  the  operation  repeated 


POST-OPERATIVE   TREATMENT,  339 

in  four  to  six  weeks  if  the  wound  show  no  tendency  to  heal. 
By  following  such  a  course  of  treatment  a  resection  or  amputa- 
tion may  finally  be  made  to  heal  permanently.  Amputation  after 
an  unsuccessful  arthrectomy  or  resection  may  become  necessary  if 
the  local  recurrence  is  extensive  and  does  not  yield  to  a  thorough 
use  of  the  sharp  spoon,  or  if  the  resection  wound  becomes  the 
seat  of  a  suppurative  inflammation,  which  proves  refractory  to 
free  drainage  and  antiseptic  irrigations.  A  diffuse  suppurative 
inflammation  following  resection  or  amputation  is  best  treated 
by  constant  irrigation  with  a  saturated  solution  of  acetate  of 
aluminum,  free  drainage,  and  covering  the  parts  with  a  thick 
hygroscopic  compress  saturated  with  the  same  solution. 


CHAPTER  XXXI. 

TUBERCULOSIS  OF  SPECIAL  BONES. 

Tuberculosis  of  the  Bones  of  the  Head. — Although  tuber- 
cular inflammation  presents  a  great  resemblance  in  the  different 
organs  and  tissues  of  the  body,  it  is  greatly  modified  by  anatomi- 
cal location  and  structure  of  the  tissues  affected,  which  influence 
the  clinical  course,  affect  the  prognosis,  and  often  require  special 
methods  of  treatment.  The  therapeutic  measures  which  are  now 
being  employed  in  the  treatment  of  tubercular  affections  of  dif- 
ferent bones  and  joints,  as  well  as  the  number  of  operative  pro- 
cedures for  their  radical  treatment,  have  become  so  numerous 
that  in  a  general  treatise  on  tuberculosis  of  bones  and  joints  it 
would  be  difficult,  if  not  impossible,  to  enumerate  and  apply 
them  with  sufficient  clearness  and  precision  to  enable  the  prac- 
titioner to  make  an  intelligent  selection  for  special  indications. 
It  is  only  too  often  the  case  that  a  method  of  treatment,  perhaps 
of  great  value  in  the  treatment  of  special  forms  of  bone  or  joint 
tuberculosis,  has  fallen  into  disrepute  because  it  was  indiscrimi- 
nately applied  in  the  treatment  of  all  forms  of  tuberculosis.  In 
the  successful  treatment  of  tubercular  affections  it  is  of  the  «reat- 

o 

est  importance  to  avoid  routine  work  and  meet  special  indications 
according  to  age  and  general  condition  of  patient,  location  and 
extent  of  disease,  and  the  presence  or  absence  of  complications. 
To  make  this  book  more  valuable  as  a  work  for  reference,  and 
as  a  guide  to  the  busy  practitioner,  I  have  deemed  it  advisable 
to  add  a  few  chapters  on  the  diagnosis,  pathology,  prognosis, 
and  surgical  treatment  of  tuberculosis  of  special  bones  and  joints. 
Bones  of  Skull. — Chronic  inflammatory  affections  of  the 
bones  of  the  skull  were  formerly  regarded  as  one  of  the  manifold 
manifestations  of  a  strumous  diathesis.  Benjamin  Brodie  ("  A 
Treatise  on  the  Diseases  of  the  Bones,"  p.  26.  London,  1828), 
in  speaking  of  scrofulous  inflammation  of  bone,  alludes  to  the 
disease  as  affecting  the  cranium  as  follows:  "When  scrofulous 
(340) 


TUBERCULOSIS   OF    SPECIAL   BONES.  341 

inflammation  attacks  the  bones  of  the  cranium  it  is  in  general 
preceded  by  inflammation  of  the  cellular  tissue  and  periosteum 
covering1  them.  A  denned  swelling,  unattended  by  pain  or 
pressure,  is  first  felt;  it  is  soft  and  elastic,  and,  in  the  course  of 
a  few  weeks,  if  left  to  itself,  an  opening  takes  place,  through 
which  is  discharged  a  sero-purulent  matter,  which  has  some- 
times, though  not  always,  a  fetid  smell.  On  introducing  a 
probe  into  the  opening  the  bone  is  found  to  be  bare,  and  some- 
times rough  on  its  surface.  After  some  time  minute  scales  of 
the  external  lamina  of  the  bone  occasionally  separate  and  are 
discharged.  If  the  disease  stop  here  granulations  arise  from 
the  diploe,  and  an  osseous  cicatrix  is  gradually  formed ;  but 
in  individuals  of  a  highly  scrofulous  diathesis,  the  disease  pene- 
trates completely  through  the  bone.  [Italics  my  own.]  Even 
after  this  untoward  event  has  taken  place,  and  when  the  gen- 
eral health  has  been  improved  by  the  exhibition  of  appro- 
priate remedies,  a  cure  is,  as  I  have  sometimes  seen,  effected 
by  means  of  the  adhesive  inflammation,  and  the  solution  of 
continuity  is  closed  up  by  a  deposition  of  a  fibre-cartilaginous 
matter." 

In  reference  to  the  cause  of  necrosis,  the  same  author  re- 
marks further:  "That  the  destruction  of  the  bone  is  not 
occasioned  by  the  pressure  of  matter,  but  by  what  Van  Helmont 
has  termed  corruptor,  and  John  Hunter  morbid  action,  in  the 
vessels  of  the  bone  itself,  is  proved  by  the  fact  that  a  similar 
result  ensues  when  an  early  opening  has  been  made  and  the 
matter  allowed  to  escape."  This  classical  description  of  the 
macroscopical  pathological  changes  which  occur  in  the  cranial 
bones  when  the  seat  of  tuberculosis  is  so  accurate  that  it  serves 
a  useful  purpose  to-day  in  giving  a  description  of  the  disease 
with  a  view  of  its  recognition  at  the  bedside. 

Cranial  Vault. — At  the  present  time  tuberculosis  of  the 
cranial  bones  is  a  well-recognized  lesion,  and,  although  not  of 
very  frequent  occurrence  as  compared  with  similar  affections 
of  other  bones,  the  clinical  observations  made  are  sufficient  to 


342 


TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 


impart  to  this  subject  a  special  interest  at  this  time.  The  flat 
bones  are  affected  in  children  and  adults.  The  frontal  bone  is 
the  most  frequent  seat,  especially  at  a  point  in  the  neighbor- 
hood of  the  orbital  margin  and  external  angular  process.  Oc- 
casionally the  parietal  and  more  rarely  the  occipital  are  also 


FIG.  40.— TUBERCULOSIS  OF  CRANIAL  BONES.  INNEK  SURFACE  OF  CRANIAL 
VAULT  AFTER  SEPARATION  OF  DURA  MATER  AND  BRAIN,  WHICH  ARE 
PUSHED  TOWARD  THE  LKFT.  (Krause.) 

a,  middle  meningeul  artery  :  h,  perforating  irregular  defect  in  parietal  bone  around  the  opening 
tubercular  eruptions  and  caseous  infiltration  of  bone ;  c,  tubercular  circumscribed  pachymeningitis. 

primarily  affected.  Local  extension  of  the  disease  is  one  of  the 
characteristic  clinical  features.  The  diplb'e  is  more  frequently 
the  primary  starting-point  than  the  periosteum.  In  the  former 
locality  it  is  met  with  either  as  a  caseous  focus  or  tubercular 
necrosis.  The  sequestra  are  generally  small, — seldom  larger 


TUBERCULOSIS   OF    SPECIAL   BONES.  343 

than  a  split  pea.  In  Volkmami's  cases  the  internal  table  was 
more  extensively  destroyed  than  the  external. 

The  cranial  affection  is  very  often  complicated  by  tubercu- 
losis in  other  organs.  Volkmann  ("Die  perforirende  Tubercu- 
lose  der  Knochen  des  Schadeldaches."  Centralblatt  f.  Chirur- 
gie,  No.  1,  1880)  gave  the  first  most  thorough  pathological  and 
clinical  description  of  this  disease.  His  paper  was  ba-sed  on 
twelve  cases  that  came  under  his  own  personal  observation,  and 
in  all  of  them  the  disease  was  located  in  the  frontal  or  parietal 
bone.  In  every  case  the  disease  was  circumscribed,  but  in- 
volved the  whole  thickness  of  the  bone,  so  that  the  caseous 
sequestrum  came  externally  in  contact  with  the  periosteum  and 
internally  with  the  dura  mater.  (Fig.  40,  c).  Almost  in  all 
cases  a  chronic  abscess  with  relaxed  walls  formed  under  the 
scalp  which  contained  genuine  tubercular  pus,  and  its  walls 
were  lined  with  fungous  granulations  in  which  tubercles  could 
be  detected.  In  six  of  the  cases  the  sequestrum  had  not  be- 
come detached,  and  was  removed  with  the  chisel ;  in  the  remain- 
ing cases  it  was  scooped  out  with  the  granulations  with  the 
sharp  spoon. 

Gangolphe  ("Tuberculose- perforante  du  crane."  Lyou 
Medicate,  No.  46,  1887)  gives  an  excellent  description  of  the 
pathological  conditions  of  one  case  of  tuberculosis  of  the  skull 
which  he  examined.  The  patient  was  a  child  4|-  years  old, 
which  died  after  resection  of  the  hip-joint.  The  immediate 
cause  of  death  was  basilar  meningitis.  Among  the  multiple 
tubercular  lesions  he  found  a  tubercular  focus  in  the  skull, 
which,  as  is  usually  the  case,  appeared  in  the  form  of  a  perfora- 
ting caseous  sequestrum  without  any  evidences  of  inflammation 
in  the  adjacent  bone  and  periosteum.  Gangolphe  makes  the 
statement  that  the  bone  is  the  primary  seat  of  this  disease,  and 
calls  attention  to  the  difference  between  it  and  syphilis  of  the 
skull,  in  which  the  bone  appears  worm-eaten,  traversed  by  fine 
spiral  channels,  while  the  tissues  around  are  swollen,  indurated, 
and  covered  by  numerous  periosteal  deposits  of  new  bone.  The 


344  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

absence  of  pain  and  tenderness  and  the  absence  of  new  bone 
within  or  in  the  immediate  vicinity  of  the  inflammatory  product 
in  tubercular  affections  of  the  cranial  bones  always  distinguish 
this  affection  from  syphilitic  lesions  in  the  same  locality.  An- 
other very  instructive  case  of  tuberculosis  of  the  cranial  vault  is 
reported  by  Israel  ("Fall  von  tuberculoser  ostitis  des  Schadels." 
Berl.  1dm.  Wochenschrift,  No.  10,,  1886).  A  boy  received  a 
slight  injury  in  the  temporal  region,  from  which  he  recovered  in 
eight  days.  Three  months  later  he  returned  to  the  hospital 
with  a  fistula  at  the  seat  of  former  injury.  The  probe  could  be 
inserted  deeply  between  the  skull  and  cranium.  Gradually 
three  swellings,  each  the  size  of  a  quarter  of  a  dollar,  appeared 
in  the  same  locality.  The  swellings  were  somewhat  tender  on 
pressure,  and  fluctuated  distinctly.  Fever  set  in,  which  was 
followed  by  serious  brain  symptoms,  vomiting,  somnolence,  and 
strabismus.  The  skull  was  exposed,  and  a  caseous  sequestrum 
was  removed.  The  dura  corresponding  with  one  of  the  foci  was 
covered  with  fungous  granulations.  Subsequently  similar  swell- 
ings appeared  in  the  direction  of  the  external  ear.  These  were 
incised  and  scraped  out,  whereupon  the  cerebral  symptoms  dis- 
appeared. Later,  the  right  ankle-joint  and  all  the  metatarsal 
joints  on  same  side  became  the  seat  of  tuberculosis.  Amputa- 
tion finally  became  necessary,  after  which  the  patient  recovered. 
In  this  case  the  cranial  disease  followed  an  injury  to  the  skull, 
and,  as  the  boy  was  in  good  health,  and  as  there  was  no  previous 
tubercular  disease  elsewhere,  it  was  in  all  probability  caused  by 
infection  through  the  wound.  That  the  extension  of  the  disease 
in  the  direction  of  the  brain  sometimes  reaches  this  organ  is 
illustrated  by  a  case  reported  by  Hauser  ("  Ueber  eineri  Fall  von 
perforirender  Tuberculose  der  platten  Schadel-Knochen,"  etc. 
Deutsches  Archiv  f.  Iclin.  Medicin,  B.  xx,  Heft  3  u.  4.  p.  267). 
The  patient  was  a  woman  51  years  old.  In  April,  1886,  she 
was  taken  with  pain  in  the  hip ;  at  the  same  time  a  cough  ap- 
peared, attended  by  purulent  expectoration.  In  June  she  sought 
hospital  treatment.  At  this  time  a  swelling  had  formed,  the 


TUBERCULOSIS   OF    SPECIAL   BONES.  345 

size  of  a  pigeon's  egg,  over  the  orbital  margin  of  the  frontal 
hone,  which  was  only  slightly  painful  and  fluctuated  distinctly. 
Under  the  swelling  the  bone  presented  a  depression,  while 
around  it  was  more  prominent.  A  second,  smaller  swelling- 
was  found  over  the  base  of  the  nose  on  the  same  side.  As  no 
bacilli  could  be  found  in  the  expectoration,  the  cranial  affection 
was  considered  as  syphilitic  in  its  nature.  Large  doses  of 
potassic  iodide  produced  no  effect.  In  June  the  abscess  was  in- 
cised and  a  colorless  fluid  escaped,  in  which  tubercle  bacilli 
were  found.  The  patient  died  the  following  month.  The 
necropsy  revealed,  besides  other  tubercular  affections,  several 
osseous  foci  in  the  cranial  vault,  and  at  one  point  the  tubercular 
process  had  extended  beyond  the  meninges  into  the  gray 
substance  of  the  brain. 

Removal  of  the  tubercular  product  should  be  undertaken 
before  sequestration  has  taken  place,  as  this  process  often  re- 
quires a  long  time,  and  as  daring  this  time  local  extension  and 
general  dissemination  are  prone  to  take  place. 

Kiimmell  ("  Zur  Trepanation  bei  Tuberculose  der  Schadel- 
Knochen."  Deutsche  Med.  Wochenschrift,  B  xiii.  p.  605).  The 
portion  of  bone  to  be  removed  can  be  outlined  accurately  by  the 
characteristic  yellowish- white  appearance  of  its  external  surface. 
As  the  internal  table  is  usually  more  extensively  involved  than 
the  external,  it  is  often  necessary  to  chip  away  with  the  chisel 
as  much  as  a  quarter  of  an  inch  of  the  surrounding  healthy 
bone  before  the  circular  sequestrum  can  be  lifted  out.  As  with 
few  exceptions  the  entire  thickness  of  the  bone  is  involved,  the 
circular  craniectomy  should  be  made  complete.  Granulations 
between  sequestrum  and  dura  are  to  be  removed  with  the  sharp 
spoon.  After  thorough  disinfection  the  defect  in  the  bone 
should  be  filled  with  a  decalcified  antiseptic  bone-disc,  which 
should  fit  the  opening  accurately,  and  the  external  wound 
sutured  except  at  the  lowest  angle,  which  is  left  open  for  a 
tubular  or  capillary  drain. 

Temporal  Bone. — The  temporal  bone  is  very  frequently 


346  TUBERCULOSIS   OP   THE   BONES   AND   JOINTS. 

the  seat  of  tuberculosis.  The  favorite  localities  are  the  internal 
ear  and  the  mastoid  cells.  That  an  ordinary  otitis  media  with 
perforation  of  the  tympanum  may  occasionally  be  transformed 
into  a  tubercular  lesion,  by  the  entrance  of  tubercle  bacilli  from 
without,  there  can  be  no  doubt.  Habermann  ("  Mittheilung  iiber 
Tuberculose  des  Gehororgans."  Prager  Med.  Wodienschrift, 
No.  6,  1885;  also  "Ueber  die  tuberculose  Infection  des  Mit- 
telohres."  Prager  Zeitschrift  fur  Heilkuude,  Band  vi)  several 
years  ago  investigated  this  subject  by  examining,  post-mortem, 
eighteen  tubercular  subjects,  in  whom  otorrhcea  or  deafness 
without  active  discharge  had  been  observed  during  life,  and  in 
nine  of  these  he  could  demonstrate  the  presence  of  tubercular 
lesions  in  the  auditory  canal.  In  one  case  he  found,  in  the  left 
auditory  apparatus,  tuberculosis  of  the  entire  middle  ear  where 
the  tympanum  was  intact.  In  another  tubercular  subject,  a 
man  38  years  of  age,  in  whom  tuberculosis  of  the  ear  was 
observed  a  year  and  a  half  before  death,  the  autopsy  revealed 
extensive  tuberculosis  of  the  cochlea,  in  the  internal  auditory 
canal,  and  in  the  superior  semicircular  canal,  while  the  other 
semicircular  canals  and  the  vestibule  were  destroyed  by  caries. 
Infection  with  the  bacillus  tuberculosis  of  granulations  in  the 
middle  ear  through  a  perforation  in  the  tympanum  can  occur  in 
persons  otherwise  in  perfect  health.  The  diagnosis  in  such 
cases  can  be  readily  made  by  removing  fragments  of  granulation 
tissue  for  microscopic  examination.  If  they  are  found  to  contain 
tubercle  bacilli  a  positive  diagnosis  has  been  made,  and  no  time 
should  be  lost  in  resorting  to  a  radical  operation. 

Habermann  regards  caries  of  the  petrous  portion  of  the 
temporal  bone  in  most  instances  as  a  tubercular  process,  caused 
by  tubercular  disease  of  the  mucous  membrane  lining  the  in- 
ternal ear.  In  order  to  prove  the  correctness  of  this  assertion 
he  did  not  rely  on  his  clinical  observations,  but  made  careful 
post-mortem  examinations  of  these  parts  after  death,  in  patients 
who  had  died  of  tuberculosis.  One  of  the  cases  he  examined 
concerned  a  woman  -32  years  of  age,  who  had  died  of  general 


TUBERCULOSIS   OF   SPECIAL   BONES.  347 

tuberculosis.  The  membrana  tympani  on  the  left  side  was 
found  intact ;  nevertheless,  he  found,  in  the  middle  ear  and  the 
mastoid  cells,  a  mass  of  cheesy  material  which  contained  numer- 
ous tubercle  bacilli.  The  mucous  membrane  of  the  middle  ear 
showed  the  characteristic  appearances  of  diffuse  tuberculosis,  and 
from  here  the  disease  had  extended  to  the  bone.  The  same  con- 
ditions existed  in  the  drum  of  the  ear,  the  process  extending 
from  within  outward.  He  believes  that  infection  occurred  by 
the  entrance  of  tubercle  bacilli  through  the  Eustachian  tube 
during  violent  attacks  of  coughing.  In  all  of  the  cases  which 
he  examined  it  was  evident  that  the  process  commenced  on  the 
surface  of  the  mucous  membrane,  and  extended  from  here  in  the 
direction  of  the  bone.  In  three  cases  the  surface  of  the  bone 
showed  evidences  of  lacunar  absorption,  while  in  two  cases  it 
was  extensively  diseased. 

Nathan  ("Ueber  das  Vorkommen  der  Tuberkel  bacillen 
bei  Otorrhoeen."  Deutsclies  ArcJdv  f.  klin.  Medicin,  B.  xxxv) 
examined  the  pus  microscopically  in  forty  cases  of  otorrhcea  and 
found  in  twelve  of  them  tubercle  bacilli.  In  eight  of  the 
patients  tuberculosis  in  other  organs  was  present.  In  three 
cases,  in  which  bacilli  were  found  in  the  pus,  no  pulmonary 
tuberculosis ;  but  in  all  of  these  the  disease  had  extended  to  the 
bone,  and  in  two  of  them  caries  of  the  bones  of  the  internal  ear 
was  present.  Voltolini  ("Ueber  Tuberkel  bacillen  im  Ohre." 
Deutsclie  Med.  Wochenschrift,  No.  31,  1884)  reports  two  cases 
of  suppurative  otitis  in  which  he  found  tubercle  bacilli  in  the 
pus.  In  one  of  them  the  patient  suffered  at  the  same  time  from 
pulmonary  and  laryngeal  tuberculosis ;  in  the  second  no  evi- 
dences of  the  disease  in  any  other  organ  could  be  found,  but 
death  occurred  from  marasmus  in  six  months.  In  the  last  case 
extensive  destruction  of  the  bony  parts  of  the  organ  of  hearing 
and  the  surrounding  bone  was  present.  As  the  Eustachian 
tubes  were  intact,  the  author  believes  that  infection  occurred 
through  the  circulating  blood.  Ritzefeld  ("  Ueber  die  Tuber- 
culose  des  Ohres."  Dissertation.  Bonn,  1884)  made  a 


348  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

bacteriological  examination  of  the  inflammatory  product  escaping 
from  the  middle  ear  in  four  patients  suffering  at  the  same  time 
from  pulmonary  tuberculosis,  and  found  tubercle  bacilli  in  all 
of  them. 

A  most  excellent  description  of  the  pathological  conditions 
found  in  tuberculosis  of  the  auditory  apparatus  and  the  temporal 
bone  in  the  pig  is  given  by  Schiitz  ("Die  Tuberculose  des 
mittleren  u.  inneren  Ohres  beim  Schweine,"  etc.  Virchow's 
ArcJiiv,  B.  Ix,  p.  93).  According  to  this  author,  the  tubercular 
process  extends  from  the  pharynx  along  the  Eustachian  tube 
to  the  middle  ear,  and  from  here  to  the  surrounding  bone,  and, 
after  perforation  of  the  membrana  tympani,  to  the  external  ear. 
The  process  often  extends  to  the  dura  mater  and  the  mastoid 
cells.  In  the  mastoid  process  the  disease  provokes  a  tubercular 
periostitis.  The  bones  of  the  internal  ear  are  often  destroyed. 
Participation  of  arachnoid,  medulla  oblongata,  and  brain  fre- 
quently takes  place.  Lymphatic  infection  and  tuberculosis  of 
other  organs  constitute  frequent  complications. 

Tuberculosis  of  the  internal  ear  and  mastoid  cells  requires 
early  and  radical  treatment  in  all  cases  in  which  the  absence 
of  serious  complications  warrants  such  treatment.  The  surgical 
treatment  must  be  conducted  upon  the  same  principles  as  when 
the  disease  is  located  in  other  accessible  organs.  The  removal 
of  the  infected  granulations  with  a  sharp  spoon,  followed  by 
irrigation  with  iodine-water  or  3-per-cent.  solution  of  boric 
acid,'  and  iodoformization  of  the  cavity  are  the  measures  to  be 
employed  in  removing  the  infected  focus  and  in  preventing  ex- 
tension of  the  disease  into  other  parts  of  the  ear,  the  mastoid 
cells,  the  meninges,  or  the  brain  itself.  The  complete  removal 
of  all  of  the  infected  tissues  will  often  render  it  necessary  to 
sacrifice  the  auditory  apparatus,  but  this  is  not  to  be  taken  into 
consideration  when  the  surgeon  is  called  upon  to  remove  a 
tubercular  focus  in  a  locality  in  which  it  can  at  any  time  be- 
come the  source  of  a  fatal  complication.  The  operation  must 
be  made  under  strict  antiseptic  precautions,  and  the  tubular 


TUBERCULOSIS   OF    SPECIAL    BONES.  349 

wound  must  be  protected  against  subsequent  infection  by  ap- 
propriate dressing.  Tubercular  mastoiditis  must  be  treated  in  a 
similar  manner  as  suppurative  inflammation  in  this  part  of  the 
temporal  bone, — removal  of  the  external  compact  layer  with  the 
chisel,  and  removal  of  the  tubercular  product  with  the  sharp 
spoon.  It  is  necessary,  in  such  cases,  to  fully  expose  the  tuber- 
cular focus  with  the  chisel,  and,  after  scraping  out  the  cheesy 
material  and  thorough  disinfection,  the  cavity  should  be  filled 
with  antiseptic  decalcified  bone-chips,  over  which  the  periosteum 
and  overlying  soft  parts  are  sutured  separately. 

Sphenoid  Bone. — Liithemuller  ("  Keilbeincaries  mit  Am- 
aurose."  Wiener  Med.  Blatter,  Nos.  1,  2,  3,  1880)  describes  a 
case  of  tubercular  caries  of  the  sphenoid  bone  in  the  person  of  a 
man  20  years  of  age,  who  suffered  for  months  from  intense 
headache,  otitis  purulenta  media  of  right  ear,  and  complete 
amaurosis.  Death  was  preceded  by  well-marked  symptoms  of 
basilar  meningitis.  The  autopsy  revealed  at  a  point  where  the 
optic  nerves  cross  each  other,  together  with  the  trigonum  olfac- 
torius  on  both  sides  and  the  tuber  cinereum  imbedded  in  a 
yellowish-gray  mass,  surrounded  by  a  vascular  layer  which  con- 
tained numerous  miliary  nodules;  in  this  mass  the  tractus  opti- 
cus  was  lost.  Beneath,  the  mass  was  connected  with  tubercular 
material,  interposed  between  it  and  the  sella  turcica  of  the 
sphenoid.  A  considerable  portion  of  the  bone  was  denuded  of 
its  covering,  and  the  disease  involved  the  bone  itself. 

According  to  the  author,  tubercular  disease  in  this  locality 
can  be  suspected  in  chronic  ozasna,  followed  by  blindness  and 
basilar  meningitis.  According  to  Borel-Laurer  ("  Sur  la  Symp- 
tomatologie  des  caries  osseuses  dans  la  profondeur  de  la  face." 
Cor.  f.  S.  Aerzte,  No.  3,  1880),  caries  of  the  ethmoid  and 
sphenoid  is  not  so  rare.  Cases  present,  besides  a  visual  disturb- 
ance, psychical  alteration,  especially  melancholy.  In  two  cases 
removal  of  the  disease  by  operation  restored  health. 

Bones  of  Face. — Tubercular  affection  of  the  facial  bones  is 
met  with  almost  exclusively  in  children,  although  I  have  seen 


350  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

two  cases  in  men  over  20  years  of  age.  The  orbital  margin  of 
the  malar  bone  is  most  frequently  the  seat  of  disease ;  next  in 
frequency  comes  the  lower  maxillary  bone.  The  upper  maxilla 
is  usually  affected  secondarily,  the  disease  extending  to  it  from 
the  periosteum  or  the  other  soft  tissue  surrounding  it.  Tuber- 
culosis of  the  malar  bone  is  attended  by  local  conditions  which 
are  pathognomonic  of  this  affection.  At  a  point  usually  near 
the  centre  of  the  orbital  margin  a  circumscribed  swelling  forms 
in  the  soft  parts  which  is  almost  painless  and  slowly  softens,  the 
skin  becomes  livid  and  attenuated,  when,  either  by  incision  or 
spontaneous  rupture,  a  small  quantity  of  tubercular  pus  is 
evacuated.  The  probe  leads  to  denuded  bone.  Later,  seques- 
tra, usually  small  in  size,  are  exfoliated  and  escape  or  are  re- 
moved, after  which  the  opening  closes  permanently,  leaving  an 
adherent  scar.  Ectropium  of  the  lower  eyelid  is  often  the 
remote  consequence  of  tuberculosis  of  the  malar  bone. 

Nasal  Bones. — Tuberculosis  of  the  nasal  bones  occurs 
either  as  a  primary  osseous  affection — tubercular  osteomyelitis 
— or  by  extension  of  tuberculosis  of  the  mucous  membrane  to 
the  subjacent  bone.  In  the  former  case  the  disease  terminates 
in  sequestration,  and  recovery  is  only  possible  after  the  spon- 
taneous elimination  or  operative  removal  of  the  tubercular 
sequestrum.  Very  often  this  disease  is  mistaken  for  ozaena  and 
treated  as  such.  The  affection  is  frequently  quite  extensive,  and 
the  diseased  bone  can  only  be  reached  and  removed  by  detach- 
ing one  side  of  the  nose  by  an  incision  carried  from  the  ala 
along  the  base  of  the  nose  as  far  as  the  eye.  In  a  case  of  this 
kind  that  I  saw  in  Prof,  von  Esmarch's  clinic,  the  disease  in- 
volved both  sides  of  the  nose,  and  in  the  operation  that  was 
performed  the  whole  nose,  as  far  as  its  root,  was  detached  and 
reflected.  This  afforded  ample  room  and  free  access  to  the 
diseased  bones. 

Kiedel  ("DieTuberkuloseder  Nasenscheidewand."  Deutsche 
Zeitschrift  f.  Chirui-gie,  B.  x,  p.  56)  has  described  a  tubercular 
affection  of  the  mucous  membrane  lining  the  cartilaginous  sep- 


TUBERCULOSIS   OF   SPE€UL   BOKM^A/:  351 

^™L£( 

turn  of  the  nose,  which,  by  extension  *t6  the  nasal  bones,  ^jv/CSKj 
rise  to  an  osseous  tuberculosis  resulting  in  caries.     In  cases  of    ' 
this  kind  the  vigorous  use  of  the  spoon  and  iodoformization  of 
the  wound  will  often  suffice  in  effecting  a  permanent  cure. 

Inferior  Maxilla.  An  interesting  case  of  extensive  tuber- 
culosis of  the  lower  jaw,  resulting  in  pathological  fracture,  is 
reported  by  Tachard  ("Fracture  pathologique  du  maxillaire 
inferieur  tuberculose  senile;  mort."  fitudes  sur  la  Tuberculose, 
T.  xi,  pp.  583-588,  1890).  The  patient  was  an  old  soldier  in 
the  Infirmary  of  the  Hotel  des  Invalides.  He  was  admitted 
in  August,  1887.  He  had  been  in  active  military  service  for 
more  than  thirty  years,  and  had  never  been  sick.  Toward  the 
latter  part  of  1886  his  strength  diminished  without  appreciable 
cause.  He  emaciated  and  was  forced  to  enter  the  civil  hospital 
at  Belfort,  where  he  received  tonic  treatment.  When  he  entered 
the  Infirmary  his  general  health  was  much  impaired ;  he  was 
languid,  pale,  emaciated.  Teeth  in  good  condition.  Never  had 
syphilis.  Coughs  little,  and  never  expectorated  blood.  Auscul- 
tation revealed  nothing  abnormal  in  the  lungs.  Urinary  and 
other  organs  presented  nothing  abnormal.  In  view  of  the 
vague  symptoms  a  positive  diagnosis  was  impossible,  and  the 
patient  was  placed  on  tonic  treatment.  August  28th,  about  two 
weeks  after  admission,  a  fluctuating  swelling  as  large  as  an 
orange  developed  on  the  right  thigh,  above  the  head  of  the 
peroneus. 

Two  aspirations  and  injections  of  iodoform  cured  the  ab- 
scess. The  general  health  of  the  patient  remained  about  the 
same  until  the  spring  of  1889,  when  a  periostitis  of  the  inferior 
maxilla  made  its  appearance  at  the  site  of  the  first  left  molar, 
which  was  extracted  many  years  before.  A  large  incision  was 
made  along  the  lower  border  of  the  jaw,  externally.  During  the 
month  of  May  the  gums  were  deeply  ulcerated  and  two  small 
sequestra  were  removed  through  the  mouth.  The  cavity  in  the 
bone  was  thoroughly  disinfected  and  through  drainage  estab- 
lished. On  July  l()th  the  jaw  fractured  while  the  patient  wa§ 


352  ^'l^ERCULOSIS   QF    THE   BONES   AND    JOINTS. 

— 1 1  >    A  i •    " "  " 

eating  his  breakfast ;  the  fracture  took  place  through  the  body 
of  l>he  bone,  at  a  point  where  the  sequestra  had  been  removed. 

*  "»    \  'l   1  \-n\  ^ 

This  accident  seriously  aggravated  the  patient's  condition.  Al- 
bumen appeared  in  the  urine,  the  feet  became  swollen,  and 
death  resulted  July  30th.  Heart  fatty;  lungs  healthy;  bron- 
chial glands  cheesy ;  liver  and  kidneys  fatty.  At  the  seat  of 
fracture  the  inferior  maxillary  bone  contained  a  typical  tubercu- 
lar focus;  loss  of  bone-substance  about  two  centimetres  in 
diameter.  Submaxillary  glands  caseous.  At  the  costo-verte- 
bral  articulations  of  the  first  and  second  ribs  on  right  side,  a 
suppurating  osteo-arthritis.  In  the  same  articulation  of  the 
fifth,  eighth,  and  ninth  ribs  are  also  small  tubercular  abscesses, 
the  largest  the  size  of  a  hazel-nut.  Another  tubercular  abscess 
was  found  behind  the  sternum,  in  communication  with  the 
fourth  and  fifth  chondro-sternal  articulations.  While  it  is 
seldom  that  the  lower  jaw  is  the  seat  of  such  extensive  destruc- 
tive changes  resulting  from  central  tubercular  osteomyelitis,  the 
periosteal  form  is  much  more  frequent.  This  passes  through 
about  the  same  changes  and  in  about  the  same  time  as  tubercu- 
losis of  the  malar  bone.  The  disease  attacks  the  outer  surface 
of  the  bone  and  the  lower  border  in  preference,  and,  after 
spontaneous  healing  or  a  cure  after  operation  has  taken  place, 
leaves  a  disfiguring  adherent  scar,  which  often  calls  for  a 
secondary  operation  to  correct  the  deformity.  I  have  repeat- 
edly met  with  this  affection  of  the  lower  jaw  in  patients  beyond 
the  age  of  puberty. 


CHAPTER  XXXII. 

TUBERCULOSIS  OF  THE  BONES  OF  THE  TRUNK. 

Tubercular  SpondyHtis. — The  bones  composing  the  spinal 
column  are  more  frequently  the  seat  of  tuberculosis  than  all  the 
remaining  bones  of  the  trunk.  Tuberculosis  of  the  vertebrae  is 
called  tubercular  spondyUtis,  and,  as  Percival  Pott  gave  the  first 
accurate  description  of  this  disease,  it  is  also  called  Pott's  disease. 
In  children  tubercular  spondylitis  is  the  most  frequent  form  of 
bone  disease.  The  middle  and  lower  dorsal  vertebrae  are  most 
frequently  affected,  then  follow  the  upper  lumbar,  and  lastly 
the  cervical, — of  the  latter,  especially  the  upper. 

Causes. — For  a  long  time  it  has  been  maintained,  by  a  few 
surgeons  only,  that  the  local  affection  produced  the  general  ill 
health  of  patients  suffering  from  disease  of  the  spine,  and  among 
those  who  entertained  this  view  belonged  Mr.  Pott.  Mr.  Pott 
(Pott's  works  edited  by  Earle,  vol.  iii,  p.  461,  edition  1790)  was 
the  first  surgeon  who  indicated  the  real  nature  of  caries  of  the 
spine.  He  expressed  himself  as  follows  concerning  its  causa- 
tion :  "  The  primary  and  sole  cause  of  all  this  mischief  is  a  dis- 
tempered state  of  the  parts  composing  or  in  immediate  connec- 
tion with  the  spine,  tending  to  and  most  frequently  ending  in 
a  caries  of  the  body  or  bodies  of  one  or  more  of  the  vertebrae; 
from  this  proceed  all  the  ills,  whether  general  or  local,  apparent 
or  concealed;  this  causes  the  ill  health  of  the  patient,  and,  in 
time,  the  curvature,  etc."  Then  originated  the  idea  that  an 
inflamed  spine  is  always  the  result  of  an  injury.  This  explana- 
tion of  the  cause  of  this  disease  is  upheld  by  many  prominent 
surgeons  even  at  the  present  time. 

Taylor  ("  Die  Orthopaedische  Behandlung  der  Pott's  chen 
Kyphose."  Berlin,  1873)  relates  that  from  1863  to  1873  eight 
hundred  and  forty-five  cases  of  Pott's  disease  of  the  spine  came 
under  his  own  observation.  In  53  per  cent,  of  these  cases  he 
was  able  to  trace  the  disease  to  a  trauma,  fall,  blow,  or  contu- 

23  (353) 


354  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

sion.  In  15^  per  cent,  pulmonary  phthisis  was  traced  in  near 
and  distant  relatives.  In  19  per  cent,  a  scrofulous  diathesis 
was  apparent ;  consequently,  taking  the  tubercular  and  scrofu- 
lous cases  together,  gives  34  per  cent,  of  all  the  cases,  while  in 
66  per  cent,  the  disease  occurred  in  otherwise  healthy  persons, 
not  affected  by  an  hereditary  taint.  In  14  per  cent,  the  disease 
led  to  the  formation  of  abscesses.  He  regards  tubercular  dis- 
ease of  the  vertebrae  as  an  exceedingly  rare  affection.  A  vast 
clinical  material  carefully  observed  by  many  competent  surgeons, 
the  co-existence  of  tubercular  affections  in  other  organs,  the 
bacteriological  examination  of  the  contents  of  abscesses  starting 
from  the  diseased  vertebrae,  and  of  the  granulations  lining  such 
abscesses,  as  well  as  numerous  post-mortem  examinations,  have 
established  the  fact  that,  with  few  exceptions,  all  cases  of  chronic 
spondyUtis  are  of  tubercular  origin  and  nature.  The  etiological 
relation  of  trauma  to  tubercular  spondylitis  is  the  same  as  to 
tubercular  affections  in  other  bones.  The  presence  of  tubercle 
bacilli  in  another  organ  or  the  circulating  blood  is  the  essential 
cause,  and  trauma  can  be  regarded  at  best  only  in  the  light  of 
an  exciting  cause.  Most  every  child  in  ordinary  health  falls 
hundreds  of  times  before  it  reaches  the  age  of  puberty,  and  yet 
tubercular  spondylitis  only  occurs  in  a  comparatively  small  per- 
centage. It  is  true  that  the  actual  development  of  the  disease 
frequently  follows  soon  after  an  injury,  but  in  many  of  these 
cases  there  can  be  but  little  doubt  that  the  tubercular  focus  was 
present  at  the  time,  and  that  the  trauma  only  aggravated  the 
local  conditions.  If  the  injury  bear  a  more  direct  causative 
relation  to  the  development  of  the  disease,  we  must  take  it  for 
granted  that  the  tissue-lesions  caused  by  it  serve  the  purpose  of 
a  locus  minoris  resistentice,  in  which  the  tubercle  bacilli  become 
arrested  and  find  a  favorable  soil  for  their  growth  and  repro- 
duction. The  spinal  column  is  so  well  protected  that  slight 
injuries  produce  no  palpable  tissue-lesions,  and  even  if  they 
were  severe  enough  to  produce  contusion  or  infraction  of  the 
bodies  of  the  vertebrae  a  tubercular  spondylitis  could  not  be 


TUBERCULOSIS  OF  THE  BONES  OF  THE  TRUNK.       355 

produced  unless  the  injured  person  furnished  the  essential  cause, 
— the  bacilli  of  tuberculosis. 

Tubercular  spondylitis  attacks  most  frequently  children  less 
than  5  years  of  age,  but  I  have  repeatedly  observed  instances 
where  it  developed  in  persons  after  the  age  of  puberty.  In  a 
paper  on  "  Pott's  Disease  in  Middle  and  Advanced  Life,"  read 
by  Mr.  Marsh  at  the  Second  Congress  of  American  Physicians 
and  Surgeons,  he  expressed  himself  as  being  in  accord  with  the 
teachings  of  Sir  James  Paget,  that  tubercular  affections  of  bones 
are  by  no  means  rare  in  the  aged.  He  referred  to  a  specimen,  in 
the  College  of  Physicians  and  Surgeons,  of  the  cervical  vertebrae 
removed  from  the  body  of  Dr.  Buckland,  Dean  of  Westminster. 
The  osseous  structure  of  the  lateral  masses  and  adjacent  parts  of 
the  atlas  and  axis  is  deeply  eroded  and  excavated,  and  the  two 
bones  are  displaced  in  relation  to  one  another.  Thus  the  appear- 
ances exactly  accord  with  those  that  are  found  in  caries  of  the 
spine  in  childhood.  The  patient  at  the  time  of  death  was  72 
years  of  age.  The  spinal  disease  was  not  detected  during  life. 

Drachmann  ("Om  Spondylitis."  Nord.  Med.  ArJdv.,  B.  vii, 
No.  17)  has  collected  one  hundred  and  sixty-one  cases  of  spon- 
dylitis, and  finds  the  following  distribution  in  reference  to  age : — 

1-  5  years, 66, — 41     per  cent. 

5-10      "  ......  58,— 36 

10-15      " 22,— 13.7  "       " 

15-20      " 8,—  5      ••       " 

20-25      "  ......       7,—  4.3  "       " 

From  these  figures  it  is  apparent  that  spondylitis  is  a  dis- 
ease of  childhood,  as  in  74.5  per  cent,  of  all  the  cases  the 
patients  were  under  10  years  of  age. 

In  regard  to  location,  these  same  cases  yield  the  following 
results : — 

One  or  more  of  the  five  lower  vertebrae, 7. 

"    "      "      "    "   four  upper  dorsal  vertebrae,     .        .        .        .20. 

"    "      "      "    "    four  middle  dorsal  vertebrae,  .        .        .        .38. 

"    "      "      "    "    four  lower  dorsal  vertebrae,     ....     45. 

The  lower  dorsal  vertebrae  and  upper  lumbar,       .        .        .        .23. 

Lumbar  vertebrae  alone,          ........     28. 

Dorsal  vertebras  most  frequently  the  seat,  103  of  all  cases,  or  64 
per  cent. 


356 


TUBERCULOSIS   OF   THE    BONES    AND    JOINTS. 


Chrystte  ("  Illustrations  of  Pott's  Disease  of  the  Spine  in 
the  Cervical  Region,"  etc.  Medical  Record,  Sept.  15,  1873) 
ascertained  that,  of  two  hundred  and  eighty  cases  of  Pott's  dis- 
ease, treated  in  the  Orthopaedic  Dispensary,  from  April,  1869,  to 

February,  1873,  in  sixty-two,  or  22 
per  cent.,  the  disease  was  located  in 
the  cervical  region. 

Pathology  and  Morbid  Anat- 
omy.— As  in  bone  tuberculosis  in 
other  localities,  the  bone  surfers 
either  primarily  or  secondarily,  by 
extension  from  the  periosteum.  The 
primary  osseous  is  much  more*  fre- 
quent than  the  periosteal  form. 
The  primary  osseous  lesion  appears 
either  as  a  cheesy  focus  or  it  is  at- 
tended almost  from  the  beginning 
by  necrosis.  In  the  vertebrae  the 
tubercular  process  is  characterized 
by  the  multiplicity  of  the  primary 
foci.  A  number  of  foci  may  be 
present  in  one  vertebral  body,  or 
they  are  scattered  over  a  number 
of  adjoining  vertebrae. 

In  some  specimens  twenty  to 
thirty,  and  even  as  many  as  one 
hundred,  distinct  foci  can  be  demon- 
strated. In  rare  cases  the  disease 
appears  as  a  diffuse  tubercular  os- 
teomyelitis. The  primary  osseous 
foci  usually  occur  in  close  proximity 
to  the  intervertebral  cartilage,  and  seldom  affect  more  than  two 
vertebrae  at  the  same  time.  The  direction  in  which  the  disease 
extends  is  usually  toward  the  anterior  surface  of  the  vertebrae, 
and  after  the  disease  has  extended  to  the  periosteum  the  ex- 


FIG.  41. — LOWER  DORSAL  AND  LUM- 
BAR PORTION  OF  SPINAL  COLUMN 
OF  CHILD.  (Krause.) 

Beginning  tubercular  spoiid.ylitis:  death  from 
general  tuberculosis ;   letters  indicate  location  of 


TUBERCULOSIS  OF  THE  BONES.  OF  THE  TRUNK.       357 

ternal  surface  of  the  bone  often  becomes  extensively  eroded. 
Secondarily  the  disease  travels  often  over  a  number  of  adjoining 
vertebrae,  the  tubercular  product  separating  the  surfaces  of  the 
vertebrae  from  the  periosteum  and  the  ligamentum  longitudi- 
nale  anterius.  Occasionally,  spurs  of  bone  form  in  the  ligament 
and  connect  the  vertebrae  by  bony  bridges,  immobilizing  the 
parts  completely. 

When  a  number  of  foci  become  confluent  the  bone  defect 
becomes  extensive,  and  it  is  in  this  manner  that  often  nearly 
the  entire  body  of  one  or  more  vertebrae  is  destroyed  and  a 
sharp  posterior  curvature  is  produced. 

Feurer  ("  Anatomische  Untersuchungen  iiber  Spondylitis." 
Arcfiiv  f.  path.  Anatomie,  B.  Ixxxii,  p.  89),  in  a  valuable  article 
on  the  histological  changes  in  the  bone  in  spondylitis,  has  shown 
that  lacunar  destruction  is  accomplished  by  the  medullary  tissue, 
in  the  majority  of  cases,  by  the  production  of  giant-cells,  but 
also  without  these.  Besides  lacunar  destruction,  he  also  de- 
scribes a  vascular  destruction  of  the  lamellae.  Vertical  to  the 
lamellae,  channels  form  twice  the  size  of  ordinary  capillary 
vessels  found  in  the  medulla,  which  permeate  the  lamella  com- 
pletely, or  terminate  blindly  in  their  middle,  or  unite  with 
each  other  in  their  interior  in  the  form  of  loops.  The  bone- 
corpuscles  were  never  seen  to  take  a  part  in  their  formation. 
These  channels  always  contain  vessels.  The  number  of  chan- 
nels is  variable,  and  never  dependent  on  the  number  of  medul- 
lary vessels.  They  bear  no  etiological  relation  to  the  lacunar 
absorption.  Of  the  greatest  importance  are  the  changes  observed 
in  the  myeloid  tissue.  They  are  initiated  with  the  diminution 
of  the  medullary  fat,  which  always  commences  first  in  the 
centre  of  the  medullary  spaces.  The  next  change  observed  is 
an  increase  of  lymphoid  cells,  especially  around  the  dilated 
blood-vessels ;  next,  proliferation  of  the  connective  tissue  takes 
place,  after  which  formation  of  tubercles  follows.  In  nine  out 
of  twelve  specimens  of  spondylitis  tubercles  were  found,  and  in 
five  out  of  these  nine  they  were  complicated  by  tuberculosis  in 


358 


TUBERCULOSIS    OF    THE    BONES    AND    JOINTS. 


other  organs. 


The  superficial  form  is  more  frequent  in  adults 
than  children,  and  is  more  frequently  associated  with  the  forma- 
tion of  diffuse  tuhercular  abscesses,  and  if  the  bodies  of  the 


FIG.   42. — TUBERCULAR  SPONDYLITIS  OF  LOWER  DORSAL,  VERTEBRA. 
Natural  size.    (Krause.) 

a  a,  very  extensive  production  of  new  bone  in  the  anterior  longitudinal  ligament,  that  has  supported 
the  spine  and  has  prevented  the  formation  of  a  gibbus  ;  b  b,  small  detects  upon  the  anterior  surface  of  the 
vertebrae. 

vertebrae  are  not  much  affected  no  curvature  is  produced.  The 
deep-seated  osseous  form  is  more  common  in  children,  and  gives 
rise  at  an  early  stage  to  posterior  curvature  of  the  spine.  The 
transverse  and  spinous  processes  are  rarely  affected  primarily, 


TUBERCULOSIS  OF  THE  BONES  OF  THE  TRUNK. 


359 


and  if  this  is  the  case  it  is  usually  caused  by  extension  of  the 
disease  from  the  periosteum  or  ligamentous  structures. 

There  is  every  reason  to  believe  that  tubercular  osteomye- 
litis not  infrequently  leads  to  extensive  changes  of  the  meninges 


FIG.  43.—  SAME  SPECIMEN,  VERTICAL  SECTION. 


a  a,  extensive  production  of  new  bone  in  the  anterior  longitudinal  ligament  ;    c,  large  tubercular 
cavity  in  the  interior  of  the  bodies  of  two  adjoining  vertebrae. 

of  the  cord  and  brain,  and  of  the  substance  of  the  cord  and 
brain  itself. 

Bampfield  ("  An  Essay  on  Curvature  and  Diseases  of  the 
Spine,"  etc.,  p.  43.  London,  1824)  was  very  well  aware  of  this 
fact,  as  may  be  seen  from  the  following  quotation  :  "  I  have 


360  TUBERCULOSIS   OP   THE   BONES   AND   JOINTS. 

been  induced  to  believe,  too,  that  inflammation  and  curvature 
of  the  spine  predispose  to  inflammation  of  the  brain,  for  in  the 
year  1822  three  patients  who  had  been  under  my  care  for  dis- 
eases of  the  spine  were  attacked  with  phrenitis  and  died, — the 
first,  a  boy,  after  having  been  cured  of  spinal  inflammation  ;  the 
second,  a  girl,  during  her  treatment  for  the  angular  projection 
of  the  spine ;  and  the  third,  a  girl,  after  having  been  cured  of 
excurvature  of  the  spine  and  sent  into  the  country."  Some  of 
the  old  authors  believed  that  the  disease  not  infrequently  com- 
menced in  the  intervertebral  cartilage.  Mr.  Stafford  ("  A  Trea- 
tise on  the  Injuries,  the  Diseases,  and  the  Distortion  of  the 
Spine,"  p.  154.  London,  1832)  says,  in  reference  to  the  primary 
seat  of  inflammation  in  disease  of  the  vertebras  :  "  Although  it 
has  been  before  stated  that  inflammation,  ulceration,  and  scrofu- 
lous disease  generally  begin  in  the  bones,  yet  in  some  instances 
they  have  appeared  to  commence  in  the  cartilage.  There  are 
some  cases  in  the  museum  of  St.  Bartholomew's  which  will 
prove  that  it  first  began  in  this  structure.  In  one  preparation, 
particularly,  every  one  of  the  intervertebral  substances  through- 
out the  whole  column  are  entirely  destroyed  by  ulceration, 
Avhilst  most  of  the  bones  are  only  slightly  affected  by  ulceration 
on  their  anterior  surfaces.  Thus,  the  bodies  of  the  vertebras,  rest 
one  upon  another  without  having  the  intervertebral  substances 
between  them."  It  is  now  generally  conceded  that  tubercular 
spondylitis  never  begins  in  the  cartilage,  and  only  seldom  affects 
the  periosteum  primarily,  but  that  in  nearly  all  cases  the  primary 
starting-point  is  in  the  bone  itself.  If  the  disease  take  an  un- 
favorable course  the  granulations  undergo  cheesy  degeneration, 
and  gradually  an  abscess  forms,  which  descends  in  a  downward 
direction  on  the  sides  or  in  front  of  the  vertebras,  which  may 
present  itself  in  the  lumbar  region  as  a  lumbar  abscess,  or  in  the 
iliac  fossa  as  an  iliac  abscess,  or,  if  it  follow  the  psoas  magnus 
as  far  as  Poupart's  ligament  or  below  it,  as  a  psoas  abscess. 
Penzoldt  ("  Ueber  die  von  Brustwir  belcaries  ausgehende 
CEsophagusperforation  und  ihre  Erkennung."  Virchow's  Archiv, 


TUBERCULOSIS   OF   THE    BONES   OF   THE   TRUNK.  361 

B.  Ixxxvi,  p.  448)  reports  three  cases  where  the  abscess,  form- 
ing in  the  course  of  dorsal  spondylitis,  perforated  into  the 
oesophagus.  In  two  of  these  cases  the  symptoms  did  not  point 
to  the  existing  condition,  while  in  the  third  the  abscess,  by  com- 
pressing the  oesophagus,  gave  rise  to  a  complexus  of  symptoms 
which  indicated  the  migration  of  the  abscess  toward  the 
oesophagus.  In  spondylitis  of  the  cervical  vertebrae  the  abscess 
may  present  itself  in  the  pharynx  or  on  the  sides  of  the  neck. 
The  spinal  cord  is  well  protected  against  invasion  by  its  cover- 
ings, but  it  occasionally  becomes  implicated  by  direct  extension 
of  the  disease  or  by  compression  in  acute  posterior  curvature  of 
the  spine.  Most  frequently  a  tubercular  pachymeningitis  com- 
plicates the  disease,  but  sometimes  all  of  the  envelopes  and  even 
the  cord  itself  is  involved.  Inflammation  of  the  spinal  nerves 
at  their  point  of  exit  from  the  vertebral  column  is  also  one  of 
the  complications  of  tubercular  spondylitis,  giving  rise  to  periph- 
eral symptoms  which  point  to  an  affection  of  the  nerve-roots. 

Symptoms  and  Diagnosis. — The  early  symptoms,  before 
the  appearance  of  deformity,  are  often  very  uncertain  and  ill 
defined.  The  first  symptom  to  attract  attention  is 

Pain. — As  the  patients  are  usually  young  children,  it  is 
very  difficult  to  locate  the  symptoms  before  the  appearance  of 
the  characteristic  deformity,  as  the  inflamed  part,  if  located  be- 
low the  cervical  vertebrae,  is  not  accessible  to  direct  examination. 
Children  complain  usually  of  pain  about  the  region  of  the 
stomach,  at  the  periphery  of  the  spinal  nerves  taking  their  exit 
from  the  inflamed  vertebrae,  instead  of  in  the  back.  This  pain 
is  aggravated  by  flexion  of  the  spine,  by  a  misstep,  and  other 
movements  which  increase  the  pressure  at  the  seat  of  disease, 
while  extension  of  the  spine  affords  relief.  The  position  of 
the  patient  must  be  regarded  as  an  early  diagnostic  sign.  The 
child  stands  and  walks  erect,  with  the  shoulders  thrown  back, 
and  is  unwilling  to  bend  the  spine  forward  when  asked  to  pick 
up  an  article  from  the  floor.  This  act  is  performed  by  squatting 
down  instead  of  bending  the  spine. 


362  TUBERCULOSIS   OF   THE   BONES   AND    JOINTS. 

Mr.  Copeland  ("Observations  on  the  Symptoms  and  Treat- 
ment of  the  Diseased  Spine,"  p.  35.  London,  1815)  has  great 
confidence  in  the  application  to  the  spine  of  a  sponge  wrung  out 
of  hot  water  and  passing  it  along  the  spine,  in  the  detection  of 
an  incipient  inflammation  in  one  or  more  of  the  vertebrae.  He 
says:  "A  sponge  wrung  out  of  hot  water  and  carried  down 
the  spine  will  often  give  a  very  acute  degree  of  pain  while 
passing  over  the  part  where  disease  is  going  on.  The  effect  of 
this  experiment  I  first  discovered  by  accident,  when  I  had  been 
applying  leeches  to  a  diseased  spine;  the  gentleman,  who  was 
my  patient,  complained  of  great  pain  when  the  hot  sponge 
came  close  to  the  projecting  vertebrae;  and,  on  reflecting  how 
much  more  sensible  of  the  power  of  heat  an  inflamed  part  was, 
I  was  led  to  repeat  the  experiment  in  every  case  of  diseased 
spine  which  offered  to  my  inspection.  .  .  .  This,  however,  may 
be  safely  concluded,  that,  although  the  absence  of  pain  on  this 
application  of  heat  is  not  an  evidence  that  there  is  no  disease,  the 
feeling  of  acute  sensation  in  any  one  part  is  sufficient  to  mark 
that  part  as  the  seat  of  the  disease."  The  increased  reflex 
irritability  often  associated  with  inflammation  of  the  vertebrae, 
more  especially  after  the  inflammation  has  extended  to  the 
envelopes  of  the  cord,  gives  rise  to  peripheral  symptoms  which 
point  to  the  central  lesion. 

Stanley  ("A  Treatise  on  Diseases  of  the  Bones."  London, 
1849)  alludes,  in  the  following  passages,  to  the  distant  and 
visceral  symptoms  associated  with  disease  of  the  vertebrae : 
"  Other  modifications  in  the  nervous  affection  are  occasionally 
observed  ;  thus,  the  irritation  of  the  spinal  cord,  instead  of  taking 
its  usual  course  downward  and  affecting  the  parts  below  the 
disease,  has,  in  rare  cases,  traveled  upward,  so  that  disease  in 
the  lower  dorsal  vertebrae  has  chiefly  affected  the  nerves  of  the 
upper  limbs.  The  internal  organs,  especially  of  the  abdomen 
and  pelvis,  variously  participate  in  the  nervous  derangements 
ensuing  from  disease  in  the  spine,  and  manifest  either  a  slow- 
ness of  their  action  or  an  apparent  increase  of  their  sensibility ; 


TUBERCULOSIS  OF  THE  BONES  OF  THE  TRUNK. 


363 


the  latter  more  particularly  occurring  in  the  mucous  surface  of 
the  bladder  and  intestines,  which,  in  some  cases,  become  so 
susceptible  of  slight  impressions  that  the  mere  touch  of  the  inside 
of  the  bladder  by  a  catheter,  or  the  slight  stimulation  of  the 
intestines  by  a  purgative,  will  directly  be  followed  by  severe 
spasms  in  the  limbs." 

Kypliosis. — Posterior  curvature  of  the  spine  takes  place  as 

soon  as  one  or  more  of  the  bodies 
of  the  vertebrae  have  become  par- 
tially destroyed  by  the  disease, 
and  the  hitter  involves  a  portion 


FIG.  44.— VERTICAL  SECTION  THROUGH 
SPINAL.  COLUMN.  One-half  natural  size. 
(Krause.) 

a.  cuneiform  destruction  of  the  fourth  lumbar  verte- 
bra ;  b,  spinoua  process  of  this  vertebra  projects  behind. 


FIG.  45.— EXTENSIVE  TUBERCULAR  DE- 
STRUCTION OF  THE  BODIES  OF  A  NUMBER 
OF  ADJOINING  DORSAL  VERTEBRA,  CAUS- 
ING A  LONG  POSTERIOR  CURVE  INSTEAD 
OF  AN  ANGULAR  GIBBUS.  One-half  natural 
size.  (Krause.) 


of  the  spine  where  this  displacement  can  take  place.  The 
most  extensive  curves  take  place  in  the  dorsal  region.  The 
extent  of  the  curve  is  not  a  reliable  indication  as  to  the  number 
of  vertebras  involved,  as,  if  the  disease  is  superficial,  a  large 
section  of  the  spinal  column  may  be  affected  and  yet  posterior 
curvature  is  absent. 


364 


TUBERCULOSIS   OF   THE    BONES    AND    JOINTS. 


A  sharp  curvature  indicates  that  not  more  than  one,  two,  or 
three  vertebrae  are  affected,  while  the  absence  of  a  sharp  pro- 
jection and  a  gentle  curve  of  the  spine  point  to  an  extensive 
disease  of  the  spine  involving  from  three  to  a  dozen  or  more  of 
adjoining  vertebrae. 


FIG.  46.— SHARP  ANGULAR  CURVATURE  OF  SPINE,  CAUSED  BY  EXTEN- 
SIVE DESTRUCTION  OF  THE  NINTH  DORSAL,  VERTEBRA.  OF  WHICH  ONLY  A 
SMALL  TRIANGULAR  PIECE  REMAINS  AT  a  ;  AT  THIS  POINT  A  FISTULOUS 
OPENING  LEADS  INTO  A  PSOAS  ABSCESS.  (Krause.) 

Usually,  the  curvature  appears  gradually,  the  bodies  of  the 
softened  and  diseased  vertebras  yielding  under  the  superimposed 
weight  of  the  body  by  degrees ;  but  occasionally  the  deformity 
comes  on  suddenly,  simulating  a  pathological  fracture  or  dislo- 
cation. This  accident  occurs  often  upon  the  slightest  application 


TUBERCULOSIS  OF  THE  BONES  OF  THE  TRUNK.       365 

of  force,  and  is  followed  by  symptoms  referable  to  compression 
of  the  spinal  cord.  In  the  case  reported  by  Bulckley  (British 
Medical  Journal,  vol.  i,  p.  517, 1880),  a  focus  was  located  in  the 
second  cervical  vertebra,  at  the  base  of  the  odontoid  process,  in 
a  child  7  years  of  age,  which  had  nearly  destroyed  the  attach- 
ment of  this  process  to  the  remaining  portion  of  the  bone,  and 
which  was  fractured  by  a  slight  blow  upon  the  back.  The 
fractured  process  was  dislocated  in  the  direction  of  the  cord,  and 
the  accident  produced  sudden  death.  The  pressure  of  the  weight 
of  the  body  exerts  itself  mostly  upon  the  anterior  portion  of  the 
inflamed  vertebrae,  where  pressure-atrophy  is  caused  first,  giving 
rise  to  wedge-shaped  loss  of  substance  in  one  or  more  of  the 
vertebrae,  which  determines  posterior  curvature,  the  production 
of  which  is,  of  course,  hastened  by  the  destruction  of  bone  by 
the  tubercular  inflammation. 

Progressive  growth  of  the  gibbus  is  prevented  by  the  for- 
mation of  new  bone,  and  when  other  parts  or  proper  mechanical 
appliances  furnish  the  necessary  support  for  the  weight  of  the 
body  above  the  diseased  vertebrae. 

Scoliosis.  —  Lovett  (British  Medical  Journal,  vol.  cxxii, 
No.  15)  made  careful  observations  upon  some  thirty  cases  of 
spinal  caries  in  reference  to  the  early  appearance  of  deformities. 
He  finds  that  in  untreated  cases  the  presence  of  lateral  devia- 
tion is  universal.  In  order  to  detect  this  deviation  of  the  spine 
it  is  necessary  to  strip  the  patient  and  look  at  him  from  the 
front.  The  deformity  consists  in  a  distinct  leaning  of  the  body 
toward  one  side  or  the  other  rather  than  a  sinuous  distortion. 
This  leaning  is  most  frequently  toward  the  right,  and  is  of  diag- 
nostic value  because  it  is  one  of  the  earliest  symptoms  of  Pott's 
disease.  Rotation  of  the  spine  is  never  as  well-marked  as  in 
scoliosis  from  other  causes. 

Paralysis. — Some  doubt  still  remains  as  to  the  immediate 
cause  of  paralysis  in  cases  of  tubercular  spondylitis.  Many 
trace  it  to  compression  of  the  cord  at  the  point  of  curvature  of 
the  spine  (Fig.  46),  while  others  believe  that,  in  most  instances, 


366  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

it  is  due  to  implication  of  the  cord  and  its  envelopes  in  the  in- 
flammatory process. 

Condroy  de  Laureal  ("  Quelques  considerations  sur  le  mal 
vertebral  chez  1'enfant."  These,  Paris,  1874)  agrees  with  Bouvier, 
that,  with  the  exception  of  the  cervical  region,  paraplegia  as  a 
complication  of  Pott's  disease  occurs  only  then,  if  the  seat  of  the 
affection  is  in  the  first  six  of  the  dorsal  vertebrae.  In  one  hun- 
dred and  thirty-six  cases  the  disease  was  located  in  the  lower 
dorsal  and  lumbar  region,  seventy-seven  times  in  the  dorsal  alone. 
In  the  first  cases  paraplegia  was  observed  only  once,  and  in  this 
case  it  followed  a  fall  and  disappeared  two  months  later.  In  the 
last  number  of  cases  paraplegia  was  noted  nineteen  times,  and 
of  this  number  the  seat  of  the  disease  involved  sixteen  times  tbe 
upper  dorsal  vertebra.  The  explanation  of  this,  as  given  by  the 
author,  is  the  fact  that  the  spinal  canal  in  the  upper  dorsal 
region  is  very  narrow  as  compared  with  the  rest  of  the  column. 

Mr.  Stafford  (  ibid.,  p.  166),  in  discussing  the  causes  of  para- 
plegia as  a  complication  of  Pott's  disease  of  the  spine,  refers  to 
both  the  effects  of  mechanical  compression  and  the  textural 
changes  of  the  cord  and  its  meninges :  "  It  may  be  observed 
also,  in  most  of  the  morbid  specimens  of  this  disease,  that  the 
vertebral  canal,  where  the  curvature  takes  place,  is  even  larger 
than  natural,  and  that  the  projecting  points  of  the  broken-down 
vertebra?  are  absorbed  and  rounded  off.  In  some  cases,  no 
doubt,  where  only  one  or  two  bodies  are  destroyed  and  the  angle 
is  very  acute,  the  bones  may  press  upon  the  spinal  cord,  but  in 
the  majority  they  do  not;  if  the  patient  live  long  enough,  there 
is  but  little  doubt  they  are,  in  general,  gradually  smoothed  down 
by  absorption.  The  state  of  the  medulla  itself,  if  examined  after 
death  of  the  part  where  the  curve  takes  place,  varies  ;  some- 
times it  does  not  in  any  way  deviate  from  health  ;  the  structure 
both  of  the  medulla  and  its  membranes  is  natural,  while  at 
other  times  a  considerable  degree  of  disease  may  have  gone  on. 
The  membranes  may  be  thickened,  matter  may  be  formed  press- 
ing upon  them,  or  between  them,  and  the  medulla  itself  may  be 


TUBERCULOSIS  OF  THE  BONES  OF  THE  TRUNK.       367 

reddened,  or  partially  softened,  or  softened  in  such  a  manner  as 
to  be  almost  in  a  fluid  state.  In  these  cases  the  paralysis  below 
is  usually  complete." 

Symptoms. — Courjon  ("  Etude  sur  la  paraplegic  dans  le 
mal  -de  Pott."  Paris,  1875)  regards  the  paraplegia  occurring 
in  the  course  of  Pott's  disease  of  the  spine  not  as  the  result 
of  mechanical  pressure  upon  the  cord,  but  as  an  evidence 
that  the  disease  has  extended  to  the  structures  of  the  meninges 
and  the  cord  itself,  giving  rise  to  structural  changes.  The 
degree  of  the  gibbus  does  not  necessarily  determine  the  paral- 
ysis, as  this  may  take  place  if  the  projection  is  but  slight.  A 
cure  may  be  effected  even  if  the  deviation  of  the  vertebral  column 
is  not  changed. 

Kahler  ("  Zur  Symptomatologie  der  Riickenmarks  compres- 
sion bei  tuberkuloser  Caries  der  unteren  Halswirbel."  Prager 
Med.  Wochenschrift,  B.  viii,  Nos.  47-50,  1883)  has  studied  this 
subject  with  special  reference  to  affections  of  the  lower  cervical 
vertebrae.  A  pachy meningitis  externa  caseosa  complicating  the 
disease  of  the  vertebrae  is  attended  by  pain  in  the  arms  and 
partial  loss  of  sensation  during  the  early  stages,  to  be  followed 
later  by  atrophy  of  some  of  the  muscles  of  the  arms  and  shoul- 
ders, with  diminution  of  irritability  to  the  electric  current.  In 
some  cases,  paralysis  and  anaesthesia  of  the  extremities  and 
trunk  develop  rapidly,  followed  by  incontinence  of  the  sphincters, 
diffuse  muscular  atrophy,  decubitus,  and  death.  Motor  dis- 
turbances, both  from  compression  and  direct  extension  of  the 
disease,  are  more  frequently  observed  than  loss  of  sensation,  be- 
cause both  of  these  causes  act  with  greater  intensity  upon  the 
anterior  than  posterior  segment  of  the  cord. 

Contractions  of  the  lower  extremity  occasionally  present 
themselves  as  peripheral  manifestations  of  the  central  nervous 
lesion.  Reflex  function  of  the  cord  is  usually  preserved,  even  if 
the  paralysis  is  complete;  but  if  the  progressive  paralysis  is  at- 
tended by  secondary  myelitis,  reflex  action  gradually  disappears. 
In  sudden  displacements  of  the  diseased  vertebras  the  paralysis 


368  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

sets  in  quickly,  but  is  not  always  caused  by  compression,  as  the 
displacement  of  the  diseased  bones  is  often  speedily  followed  by 
myelitis. 

Temperature. — Although  fever  is  not  usually  present  in 
chronic  spondylitis,  it  very  often  attends  acute  cases.  Lovett 
("  The  Diagnosis  of  Pott's  Disease."  American  Journal  Medi- 
cal Sciences,  December,  1891)  has  recently  called  attention  to 
high  evening  temperature  as  a  constant  symptom  in  the  acute 
stages  of  tubercular  spondylitis.  According  to  his  observations 
the  rise  of  temperature  is  from  one  to  three  degrees,  and  in 
general  it  can  be  accepted  as  indicating  roughly  the  degree  of 
severity  of  the  disease.  The  temperature  did  not  seem  to  be 
influenced  by  the  formation  of  abscess. 

Prognosis. — As  a  rule,  tuberculosis  of  the  spine  pursues  a. 
chronic  course,  but  exceptionally  it  appears  as  an  acute  affection 
attended  by  fever  and  other  symptoms  suggesting  a  general 
disease.  Patients  may  die  in  a  short  time,  and  the  diagnosis  of 
a  diffuse  acute  tubercular  spondylitis  is  only  made  in  the  post- 
mortem room.  The  prognosis  is  always  more  favorable  in 
children  than  adults.  Abscess  adds  to  the  gravity  of  the  case. 
Bampfield  ("  An  Essay  on  Curvature  and  Diseases  of  the  Spine," 
etc.,  p.  85.  London,  1824)  was  well  aware  of  the  dangers 
which  attend  the  formation  of  an  abscess  in  connection  with 
Pott's  disease,  as  can  be  learned  from  the  following  sentence : 
"  When  curvature  is  caused  by  caries  of  the  vertebrae  or  gan- 
grenous destruction  of  the  intervertebral  substance,  the  prognosis 
should  be  unfavorable,  and  if  caries  be  combined  with  the  ap- 
pearance of  external  abscess  communicating  with  the  diseased 
vertebra?,  whether  the  abscess  have  the  name  of  lumbar,  psoas, 
or  any  other  appellation  or  situation." 

Townsend  ("  The  Treatment  of  Abscesses  of  Pott's  Dis- 
ease." Medical  Neivs,  December  19,  1891)  gives  the  ultimate 
result  in  seventy-five  cases  of  abscess  of  the  spine,  and  from  the 
tables  given  it  would  appear  that  the  prognosis  in  such  cases  is 
not  as  favorable  as  has  generally  been  supposed : — 


TUBERCULOSIS    OF   THE    BONES    OF    THE   TRUNK.  369 

ANALYSIS  OF  SEVENTY-FIVE  CASES  OF  ABSCESSES  OF  POTT'S  DISEASE. 

No  treatment  but  brace  ;  abscess  disappeared,         ....      3 

"       abscess  in  statu  quo,        ....      8 

"        "       abscess  increasing,  child  doing  well,       .      8 

"        "       child  not  doing  well,        ...        .        .2 

~21 

ASPIRATION. 

Abscess  disappeared,          .         .        .        .        .        ....     11 

Abscess  opened  spontaneously  after  aspiration  failed,     ...      3 

Abscess  incised  after  aspiration  failed, 4 

Abscess  in  statu  quo  after  aspiration  failed,      .....       1 

.19 
Number  of  aspirations  in  each  case,  from  2  to  6, — average  3. 

INCISIONS — SCRAPING  SAC. 

With  use  of  iodoform-emulsion  or  peroxide  of  hydrogen,        .        .          14 

Results,  good -  .        .        .    •    .        .  11 

Results,  bad,       .        .      •  .  .•     :  .        .        .    '.-';        .        .  3 

Infected  at  time  of  operation  or  at  subsequent  dressings,        .        .  11 

Not  infected, 3 

OPENED   SPONTANEOUSLY. 

Results,  good, 15 

Results,  bad, 6 

~*L 

75 

DEATHS. 

•    Tubercular  meningitis, 2 

Amyloid  liver,    .        . 2 

Suppression  of  urine, 1 

5 

The  symptoms  are  often  misleading,  as  to  the  final  outcome. 
Thus,  Konig  observed  two  cases  of  tubercular  spondylitis  in  the 
lower  cervical  vertebrae,  in  children,  which  had  resulted  in  com- 
plete paraplegia,  and  yet  both  patients  recovered  completely.  A 
process  of  repair  may  be  initiated  at  any  time.  If  the  dorsal 
vertebrae  are  affected  and  a  well-marked  posterior  curvature  of 
the  spine  has  taken  place,  the  ribs  finally  furnish  the  necessary 
support  and  these  rest  again  on  the  pelvis ;  and  when  the  in- 
flamed parts  are  in  a  condition  of  rest  and  immobilization,  a 
plastic  or  reparative  process  is  substituted  for  the  destructive 
lesion,  and  recovery  by  bony  ankylosis  results.  If  a  migrating 
abscess  communicating  with  diseased  vertebrae  open  sponta- 
neously, or  infection  take  place  after  incision  and  drainage,  the 

24 


370  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

prognosis  is  always  rendered  dubious.  Secondary  infection  with 
pus-microbes  leads  to  profuse  suppuration,  hectic  fever,  and,  if 
death  does  not  occur  from  these  complications,  danger  to  life  is 
threatened  later  from  amyloid  degeneration  of  internal  organs. 
Spontaneous  elimination  of  necrosed  bone  may  take  place, 
followed  by  recovery.  This  favorable  termination  has  been 
repeatedly  observed  in  disease  of  the  upper  cervical  region,  when 
recovery  followed  after  the  escape  of  sequestra  from  the  atlas  or 
epistropheus  through  a  fistula  in  the  pharynx.  In  reference 
to  deformity,  it  can  be  said  that  well-directed  mechanical  treat- 
ment can  do  a  great  deal  against  the  prevention  of  posterior 
curvature,  but  the  same  treatment  is  powerless  in  correcting  it. 
On  the  whole,  the  outlook  in  cases  of  tubercular  spondylitis  is 
anything  but  encouraging.  Boeckel  gives  an  account  of  eight 
cases,  and  among  them  not  a  single  case  of  complete  recovery, — 
two  local  relapses  and  five  deaths  from  pulmonary  tuberculosis, 
and  in  one  case  the  final  result  was  not  known.  Even  in  cases 
where  the  patients  have  apparently  recovered,  relapse  may  take 
place  at  any  time,  and  it  is  seldom  that  a  child  who  suffers  from 
this  disease  reaches  old  age. 

Treatment.  —  As  tubercular  lesions  in  the  bodies  of  the 
vertebra  and  in  the  joints  between  them  are  inaccessible  to 
direct  surgical  interference,  the  treatment  to  be  relied  upon  in 
these  cases  must  consist  in  supporting  the  patient's  strength  by 
a  liberal  diet,  out-door  air,  and  the  internal  use  of  tonic  and 
nutritive  remedies,  subcutaneous  medication  and  the  employ- 
ment of  mechanical  measures  to  secure  rest  for  the  diseased 
vertebrae. 

Counter-irritation. — This  method  of  treatment  is  mentioned 
here  simply  for  the  purpose  of  giving  the  treatment  of  Mr.  Pott, 
who  describes  (loc.  cit.,  p.  471)  his  method  of  cure  as  follows: 
"It  consists  merely  in  procuring  a  large  discharge  of  matter 
from  underneath  the  membrana  adiposa,  on  each  side  of  the 
distempered  bones,  forming  a  curvature,  and  in  maintaining  such 
discharge  until  the  patient  shall  have  recovered  his  health  and 


TUBERCULOSIS  OF  THE  BONES  OF  THE  TRUNK.       371 

limb."  He  strongly  disapproves  of  the  application  of  any  me- 
chanical instrument  whatever,  and  has  no  faith  in  the  internal 
use  of  drugs.  Mr.  Sheldrake  ("  A  Treatise  on  Diseased  Spine," 
p.  17.  London,  1816)  adopted  the  treatment  advised  by  Mr. 
Pott,  but  combined  it  with  the  employment  of  mechanical  appli- 
ances. It  is  fortunate  that  counter-irritation  in  the  treatment 
of  tuberculosis  of  the  spine  as  well  as  of  other  bones  has  been 
abandoned  long  ago,  and  it  is  safe  to  predict  that  it  will  never 
come  into  use  again.  It  is  difficult  to  conceive  how  much  suffer- 
ing and  misery  was  inflicted  by  this  method  of  treatment  upon  a 
class  of  patients  least  calculated  to  bear  such  treatment. 

Rest  and  Extension.  —  Rest  and  extension  are  the  two 
essential  conditions  which  place  the  inflamed  vertebrae  -in  the 
most  favorable  condition  for  the  substitution  of  a  reparative  for 
a  destructive  process,  as  well  as  in  the  prevention  of  deformity. 
These  requirements  in  the  treatment  of  tubercular  spondylitis 
can  only  be  fully  realized  by  keeping  the  patient  in  the  supine 
position,  and  to  a  lesser  extent  by  efficient  mechanical  support 
and  immobilization  of  the  spine.  In  dwelling  on  the  importance 
of  lifting  the  weight  of  the  body  off  from  the  diseased  vertebras, 
Mr.  Bampfield  ("An  Essay  on  Curvature  and  Diseases  of  the 
Spine,"  etc.,  p.  130.  London,  1824),  in  his  interesting  work, 
gives  the  following  directions  :  "  For  the  correct  and  clear  com- 
prehension, therefore,  of  the  terms  and  operations  mentioned  in 
this  dissertation,  it  is  necessary  to  state  that  three  variations  of 
the  horizontal  position  will  be  employed  in  the  treatment, — the 
dorsal  horizontal  position,  or  lying  on  the  back ;  the  facial  hori- 
zontal position,  being  the  reverse  of  the  former,  or  what  in  com- 
mon language  is  called  '  lying  on  the  face,'  of  course,  in  a  line 
with  the  sternum  and  linea  alba  abdominis  ;  the  lateral  hori- 
zontal position,  or  lying  on  either  side.  Time  required  by  this 
treatment,  from  three  to  six  months."  In  speaking  of  exten- 
sion the  same  author  (op.  cit.,  p.  130)  says:  "Some  machine 
makers,  to  whom  deformed  persons  resort  for  their  cure,  suspend 
their  patients  by  their  necks,  through  the  medium  of  ropes  and 


372 


TUBERCULOSIS   OF    THE    BONES    AND    JOINTS. 


compound  pulleys,  by  which  they  presume  they  can  straighten 
their  spines  (italics  my  own) ;  but,  besides  that  the  practice  is 
dangerous  in  cases  where  the  bodies  of  the  vertebae  are  carious  or 
destroyed,  it  has  more  effect  in  stretching  the  ligaments  and  in- 
creasing the  size  of  the  muscles  of  the  neck  which  are  principally 
called  into  action  by  the  position  than  it  has  in  curing  the  de- 
formity." The  dorsal  horizontal  position  should  be  advised  in 
all  cases  that  appear  to  pursue  a  rapid  course,  and  whenever  the 
patient  suffers  acute  pain.  The  patient  should  be  placed  in  a 


FIG.  47. — SPONDYLITIS  OP  MIDDLE  DORSAL  VERTEBRAS     RAUCHFUSS'S  APPARATUS 
COMBINED  WITH  HEAD-EXTENSION  BY  GLISSON'S  SWING.    (Krause.) 

single  bed  provided  with  a  smooth  hair  mattress,  and  extension 
can  be  made  at  the  same  time  by  placing  him  upon  Rauchfuss's 
swing. 

Rauchfuss's  extension  bandage  consists  of  a  strip  of 
cloth  from  six  to  eight  inches  in  width,  which  is  fastened  to  each 
side  of  the  bed  a  few  inches  above  the  mattress,  and  upon  which 
the  patient  is  placed  in  such  a  manner  that  the  curvature  rests 
upon  the  centre  of  the  swing. 

At  the  second  meeting  of  the  American  Congress  of  Phy- 
sicians and  Surgeons,  the  treatment  of  spondylitis  received  a 


TUBERCULOSIS  OF  THE  BONES  OF  THE  TRUNK. 


373 


great  deal  of  attention  in  the  Orthopaedic  Section.  Weigel,  of 
Rochester,  and  Vance,  of  Louisville,  strongly  advised  vest  in  the 
recumbent  position  until  the  active  symptoms  have  suhsided. 
Foster,  of  Cambridge,  combines  this  treatment  with  extension, 
especially  if  the  disease  involve  the  cervical  vertebrae.  Ex- 
tension is  obtained  by  weights,  the  cords  running  over  the  head 
and  foot  of  the  bed,  and  being  attached  to  waist-belts,  chest- 
belts,  or  Sayre  head-straps.  In  spondylitis  of  the  cervical  ver- 
tebrae rest  in  bed  can  be  combined  with  extension  by  means  of 
weight  and  pulley,  as  advised  by  Volkmann.  (Fig.  47).  If  the 


FIG.  48. —CARIES  OF  LOWER  LUMBAR  VERTEBRA     RAUOHFUSS'S  APPARATUS  WITH 
EXTENSION  ON  BOTH  LEGS.    (A'rause.) 

disease  is  located  in  the  lumbar  or  lower  dorsal  region,  extension 
can  be  most  effectually  applied  by  placing  the  patient  in  the 
dorsal  supine  position,  the  gibbus  resting  on  Rauchfuss's  appa- 
ratus and  moderate  extension  by  weight  and  pulley  on  both  legs. 
Rest  in  bed  should  be  enforced  until  the  active  symptoms 
of  inflammation  have  subsided,  which  will  be  indicated  by  sub- 
sidence of  pain.  At  this  time  a  portable  apparatus  should  be 
applied.  I  will  not  occupy  space  uselessly  by  giving  descriptions 
of  the  numerous  machines  which  have  been  devised  for  this 
purpose,  as  none  of  them  have  answered  the  expectations. 


374 


TUBERCULOSIS   OF   THE    BONES    AND    JOINTS. 


Sayre's  plaster-of-Paris  jacket,  applied  while  the  patient  is 
partly  suspended,  answers  a  more  useful  purpose  than  any  of 
the  numerous  complicated  and  expensive  apparatuses  which 
have  been,  as  yet,  invented. 

To  apply  the  jacket  properly  requires  a  great  deal  of  ex- 
perience and  the  exercise  of  considerable  skill.  In  many  com- 
munities this  method  of  treatment  has  become  unpopular,  both 
among  physicians  and  the  laity,  from  the  bad  results  caused  by 

improper  application  of  the  corset. 
Hyperextension  must  be  care- 
fully avoided,  and  when  old  enough 
the  patient  must  be  instructed  to 
extend  himself  only  to  the  point 
where  pain  is  relieved,  and  not  be- 
yond this  point,  which  well  deserves 
the  designation  "  point  of  comfort." 
The  bony  prominence  at  the  seat 
of  curvature  must  be  carefully  pro- 
tected against  pressure  by  apply- 
ing, on  each  side,  a  firm  pad  suffi- 
ciently thick  to  prevent  contact  of 
the  projecting  spinous  processes 
with  the  plaster  cast.  The  plaster 
bandages,  freshly  prepared,  are 
immersed  in  lukewarm  water  until 
carbonic  acid  ceases  to  escape, 
when  they  are  smoothly  applied,  so  that  after  extension  is  re- 
moved the  cast  will  be  accurately  molded  to  the  unequal  surface 
of  the  body.  The  body  should  be  protected  by  a  knit,  closely- 
fitting  shirt.  If  the  disease  is  located  in  a  cervical  or  upper 
dorsal  vertebra,  extension  is  made  by  a  jury-mast. 

Another  matter  of  great  importance  is  to  see  the  patient  from 
time  to  time,  in  order  to  determine  whether  the  jacket  causes 
injurious  pressure  at  any  point,  which,  if  this  should  be  the 
case,  is  remedied  at  once,  either  by  cutting  out  that  portion  of 


FIG.  49.— SAYRE'S  SUSPENSION 
APPARATUS  . 


TUBERCULOSIS  OF  THE  BONES  OF  THE  TRUNK. 


375 


the  jacket  which  has  caused  the  decubitus  or  by  applying  a  new 
one.  It  is  necessary  to  renew  the  jacket  every  six  to  twelve 
weeks,  as  in  that  time  it  becomes  loose  and  no  longer  furnishes 

the  requisite  mechanical  support. 
Felt  and  other  plastic  material  has 
been  used  as  a  substitute  for  plaster- 
of-Paris,  but  none  of  them  have 
proved  superior  to  this  material  when 
properly  used,  and  all  of  them  require 
more  time  and  skill  in  their  applica- 
tion. The  mechanical  treatment  by 
extension  and  fixation  must  be  con- 
tinued several  months  after  all  inflam- 


FIG.  50. — CHILD  SUSPENDED  AND  READY 
FOR  APPLICATION  OF  PLASTEK-OF-FARIS 
BANDAGE. 


FIG.  51.— SPONDYLITISOF  UPPER  DORSAL 
VERTEBRA.  SAYRE'S  PLASTER-OF-PARIS 
JACKET,  WITH  JURY-MAST.  VOLKMANN'S 
WALKING-STOOL.  (Krauze.) 


matory  symptoms  have  subsided,  as  too  early  suspension  of  this 
part  of  treatment  has  often  been  followed  by  a  local  relapse. 

lodoformization  of  Abscess.  —  The  value  of  subcutaneous 
iodoformization  has  been  most  apparent  in  the  treatment  of  tuber- 


376  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

cular  abscesses  originating  from  diseased  vertebrae.  No  modern 
progressive  surgeon,  at  the  present  time,  would  entertain  the 
idea  for  a  moment  of  resorting  to  operative  procedures  without 
having  given  this  method  of  treatment  a  fair  trial.  I  regard 
this  treatment  as  one  of  the  greatest  advances  in  the  struggle 
against  tubercular  affections  of  inaccessible  bones  like  the  verte- 
brae. In  my  own  hands  it  has  yielded  brilliant  results  in  cases 
that  without  it  would  certainly  have  been  hopeless.  I  have  seen 
iliac,  lumbar,  and  psoas  abscesses,  the  size  of  a  child's  head,  in 
communication  with  tubercular  disease  of  the  vertebrae,  definitely 
heal  after  three  or  four  evacuations,  followed  by  irrigation  and 
injection  of  a  10-per-cent.  emulsion  of  iodoform  in  glycerin. 

Bruns  (Beltrdge  f.  Minische  Chirurgie,  B.  iv,  Heft  1)  has 
collected  thirty-five  cases  of  tubercular  abscess,  originating  in 
the  vertebrae  and  presenting  themselves  clinically  as  psoas  ab- 
scesses, treated  by  iodoform  injections ;  twenty-four  of  this  num- 
ber were  completely  cured,  five  improved,  and  in  two  the  result 
remains  unknown.  The  author  concludes,  from  these  figures 
and  his  own  experience,  that  the  iodoform  treatment  of  these 
abscesses  is  most  encouraging.  Bonilly  injects  sinuses  with 
chloride-of-zinc  solution,  and  Verneuil  uses  iodoform  ether, 
Schede  corrosive  sublimate,  Perier  salol  ether,  and  Reboul 
naphthol  camphor  for  the  same  purpose.  Heuter  advised  paren- 
chymatous  injections  into  and  around  the  diseased  vertebrae  of 
solutions  of  carbolic  acid  as  early  as  1879.  I  cannot  recommend 
too  strongly  the  method  of  subcutaneous  injection  of  iodoform 
after  evacuation  of  tubercular  abscesses  in  the  treatment  of 
tuberculosis  of  the  spine.  For  further  information  regarding 
the  technique  of  the  procedure  the  reader  is  referred  to  the 
chapter  in  which  this  subject  is  fully  discussed. 

Operative  Treatment. — The  operative  treatment  of  tuber- 
cular spondylitis  has  for  its  objects  the  modern  management  of 
the  abscess,  after  such  has  formed,  and  the  removal  of  the  im- 
mediate causes  of  compression  if  the  disease  has  produced  pa- 
ralysis by  compression  of  the  spinal  cord  or  by  extension  to  its 


TUBERCULOSIS  OF  THE  BONES  OF  THE  TRUNK.       377 

coverings.  Lannelongue  favored  opening  and  scraping  of  cold 
abscesses  developing  in  connection  with  diseased  vertebrae  in 
1881,  and  Ileclus  adopted  this  plan  of  treatment  in  1886.  This 
treatment  was  later  indorsed  by  Bouilly,  Socin,  Boeckel,  Volk- 
mann,  Lesser,  Routier,  Quenu,  and  Leriche.  The  protection 
afforded  by  following  strict  antiseptic  precautions  during  and 
after  the  operation  reduced  the  danger  of  this  procedure,  but  did 
not  displace  it,  and  at  the  present  time  few  would  dare  to  open 
an  abscess  still  remaining  in  communication  with  tubercular 
foci  in  the  spine.  In  my  own  practice  I  have  succeeded  twice 
in  preventing  infection  subsequently  after  opening  and  scrap- 
ing a  lumbar  abscess,  and  definite  healing  was  obtained  without 
a  drop  of  pus;  but  more  frequently  I  have  only  been  able  to 
maintain  an  aseptic  condition  for  a  number  of  weeks,  when 
finally  infection  occurred  during  the  dressing  or  by  displace- 
ment of  the  dressing,  and  profuse  suppuration  set  in,  with  all  the 
immediate  and  remote  consequences.  Incision  and  scraping 
should  only  be  resorted  to  when  the  abscess  threatens  to  open 
spontaneously ;  in  such  cases  it  is  not  only  proper,  but  absolutely 
necessary,  to  interfere,  in  order  to  secure  for  the  interior  of  the 
abscess  and  the  primary  foci  in  the  bones  an  aseptic  condition, 
Attempts  have  been  repeatedly  made  to  attack  the  primary  bone 
disease.  Boeckel  (Gaz.  heb.  de  Strassburg)  made  an  ecidement 
vertebrale  in  1882;  Israel  (Berl.  Idin  Wochenschrift,  March  9, 
1882)  scraped  the  body  of  the  twelfth  dorsal  vertebra  the  same 
year;  Polaillon  (Union  Medicale)  resected  two  spinous  apophy- 
ses  in  1883;  Uclorme  (These  de  Faucillon,  1887)  scraped  the 
body  of  the  twelfth  dorsal  vertebra,  and  Labbe  attacked  one  of 
the  sacral  vertebrae  for  a  tubercular  affection. 

Chipault  (Archiv  Gen.  de  Med.,  December,  1890)  has  col- 
lected thirty-five  cases  of  Pott's  disease  treated  surgically,  and 
he  states  that  out  of  this  number  twenty  were  improved  or  defi- 
nitely cured.  In  the  cases  where  the  operation  proved  successful, 
progress  toward  recovery  went  on  slowly,  but  uninterruptedly. 
When  the  operation  was  done  for  paralysis  sensation  re-appeared, 


378  TUBERCULOSIS   OF   THE   BONES    AND    JOINTS. 

first  from  above  downward;  motion  later,  and  in  an  opposite 
direction.  The  sphincters  recovered  early.  The  fifteen  cases 
not  improved  divide  themselves  into  two  groups, — («.)  those  in 
which  primary  improvement  is  followed  by  return  of  symptoms, 
and  (6)  those  in  which  the  operation  is  without  effect.  In  the 
first  group  the  cause  of  recurrence  may  be  the  supervention  of 
acute  curvature,  or  the  re-growth  of  granulations.  The  second 
source  of  failure  is,  in  some  cases,  an  incomplete  removal  of 
granulations;  in  others,  possibly,  a  too  great  destruction  of  the 
cord-tissue.  Of  ten  deaths,  three  were  due  to  injury  to  the 
cord  at  the  time  of  operation,  four  to  general  tuberculosis,  and 
two  to  the  severity  of  pre-existing  complications. 

The  author  concludes  that  we  should  operate  only  when 
the  general  health  is  good,  and  when  the  spinal  symptoms  are 
severe  and  do  not  yield  to  other  treatment.  Children  do  much 
better  than  adults.  Of  bad  prognostic  import  is  a  high  position 
or  extensive  distribution  of  the  disease.  Scraping  of  fistulous 
tracts  should  be  carried  as  far  toward  the  primary  starting-point 
of  the  abscess  as  possible,  and  must  always  be  done  under 
strictest  antiseptic  precautions.  If  necessary,  counter-openings 
can  be  made.  lodoform  tampon  and  secondary  suturing  will  give 
better  results  than  immediate  suturing  and  tubular  drainage. 

Laminectomy  or  Lamnectomy. — This  operation  was  first 
suggested  by  Heister  ("  A  General  System  of  Surgery."  Seventh 
edition,  Book  I,  Chapter  vi,  p.  143.  London,  1745),  while  the 
first  attempt  to  remove  depressed  fragments  of  a  broken  arch 
was  made  by  Louis  (Chipault,  Gaz.  des  Hop,  p.  809,  September 
13,  1890).  The  first  well-planned  and  intentional  operation  on 
the  spine  for  subcutaneous  lesion  was  performed  by  Mr.  Henry 
Cline  (South's  Chelius,  vol.  i,  p.  539.  London,  1847). 

Macewen,  in  1888  {British  Medical  Journal,  August  llth), 
reported  a  number  of  cases  of  paralysis  resulting  from  compres- 
sion in  Pott's  disease  of  the  spine,  benefited  and  cured  by 
removing  two  or  more  of  the  arches  of  the  vertebrae.  Only  in 
exceptional  cases  is  the  mechanical  pressure  the  only  cause  of 


TUBERCULOSIS   OF   THE   BONES   OF   THE   TRUNK.  379 

paralysis.  If  the  paralysis  appear  suddenly,  it  is  the  result  of 
a  slipping-  of  the  diseased  vertebrae  upon  each  other, — spondylo- 
listhesis, — in  which  case  operative  interference  would  not  be 
justifiable.  Replacement  by  extension  is  the  thing  to  be  at- 
tempted. The  extension  of  the  tubercular  process  toward  the 
cord  is  impeded  first  by  the  periosteum ;  but  after  this  barrier 
has  been  overcome,  the  epidural  space,  with  its  loose  cellular 
tissue,  furnishes  a  good  locality  for  the  diffusion  of  the  tubercu- 
lar process.  The  inflammatory  product  is  often  quite  copious 
in  this  place,  and  pushes  the  dura  in  the  direction  of  the  cord. 
Sometimes  a  real  tubercular  abscess  develops  here.  The  dura 
offers  great  resistance  to  the  progress  of  the  disease,  but  finally 
becomes  implicated  and  a  tubercular  pachymeningitis  is  the 
result,  preceded  by  a  peri-pachy meningitis.  The  tubercular 
process  extends  itself  first  on  the  outer  surface,  causing  a  pachy- 
meningitis externa,  and  the  internal  surface  is  seldom  found 
affected;  if,  however,  the  patient  live  long  enough,  the  disease 
finally  penetrates  the  membrane.  Compression  of  the  cord 
often  takes  place  in  a  sufficient  degree  before  the  dura  is 
involved. 

Schmaus  ("Die  Compressions  Myelitis  bei  Caries  der  Wir- 
belsaule."  Wiesbaden,  1890)  gives  an  account  of  fifty-two  post- 
mortem examinations  of  spondylitic  paralysis.  Among  these, 
not  less  than  thirty-two  showed  well-marked  evidences  of  com- 
pression of  the  cord.  Kahler  ("Ueber  die  Veranderungen, 
welche  sich  im  Riickenmarke  in  Folge  einer  germgo-radigen 
Compression  entwickeln."  ZeitscJirift  fur  Heilkunde,  B.  iii. 
Prag,  1882)  has  shown  experimentally  that  a  very  slight  degree 
of  compression  of  the  cord  is  followed  by  oedema  and  structural 
changes  leading  to  paralysis.  In  consequence  of  such  vascular 
changes  the  nerve-elements  degenerate,  and  their  place  is  taken 
by  connective  tissue.  He  has  demonstrated  that  a  moderate 
encroachment  upon  the  spinal  cord  cannot  endanger  its  function, 
provided  anatomical  structure  is  not  interfered  with. 

Striimpell  has  claimed,  on  good  grounds,  that  compression 


380  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

myelitis  in  reality  is  not  an  inflammatory  but  a  degenerative 
process.  In  some  cases,  however,  the  disease  reaches  the  pia  and 
cord  itself,  and  then  the  designation  myelitis  tubercutosa  would  be 
proper.  If  paralysis  is  found  without  much  displacement  of 
vertebrae,  it  must  be  caused  by  compression  from  inflammatory 
product  within  the  canal.  Of  the  fifty-two  cases  reported  by 
Schmaus,  the  cause  of  compression  is  specified  in  thirty-nine. 
Among  these  it  was  due  to  a  caseous  pachymeningitis  in 
thirty-three ;  six  times  it  was  caused  by  deviation  of  the  affected 
vertebrae.  The  operation  of  opening  the  spinal  canal  should  not 
be  undertaken  without  positive  indications.  Gradual  increase 
of  paralysis  points  to  compression  from  inflammatory  product 
within  the  canal,  and  this  supposition  is  sustained  if  the  disease 
is  attended  by  symptoms  which  point  to  an  affection  of  the  roots 
of  the  spinal  nerves.  Operation  should  be  preceded  by  extension 
treatment. 

Kraske  ("  Operative  Eroffnung  des  Wirbelcanales  bei 
spondylitischen  Lahmungen."  Archiv  f.  klinische  Chiruryie) 
has  written  a  very  valuable  and  practical  monograph  on  the 
surgical  treatment  of  paraplegia  resulting  from  spondylitis.  He 
bases  his  remarks  on  a  study  of  the  pathological  conditions  of 
seventy  cases.  The  author  differs  from  Macewen  and  the 
majority  of  surgeons  who  attribute  the  paralysis  to  compression 
of  the  cord,  and  advances  the  idea  that  the  paralysis  does  not 
result  from  compression,  but  from  participation  of  the  cord  or 
its  meninges  in  the  inflammatory  process,  and  on  this  account 
he  urges  that,  even  with  the  most  positive  diagnosis,  operative 
treatment  should  be  preceded  by  persistent  local  treatment  in 
a  reclining  position. 

In  illustration  of  the  treatment  outlined  by  him,  and  as 
samples  of  the  pathological  conditions  which  the  surgeon  has  to 
deal  with  in  these  cases,  I  will  briefly  outline  the  four  cases  that 
came  under  Kraske's  personal  observation.  The  first  case  was 
a  woman  57  years  old,  who  had  already  passed  through  several 
multiple  tubercular  affections.  She  was  suddenly  attacked  by 


TUBERCULOSIS   OF    THE    BONES   OF    THE    TRUNK.  381 

pain  in  the  thoracic  portion  of  the  spine,  chiefly  radiating  to 
the  right  and  soon  followed  by  complete  paraplegia.  There  was 
no  curvature,  hut  tenderness  on  pressure  upon  the  fifth  and  sixth 
spinous  processes.  The  formation  of  an  abscess  at  this  place 
invited  prompt  action.  The  abscess  was  freely  incised  and 
scraped.  The  arch  of  the  fifth  dorsal  vertebra,  having  under- 
gone extensive  tubercular  destruction,  was  removed.  Underneath 
the  arch  a  teaspoon ful  of  tubercular  pus  and  a  mass  of  granu- 
lation tissue  were  found.  After  the  removal  of  the  granulations 
from  the  outer  surface  of  the  dura,  the  pulsations  of  the  cord 
could  be  distinctly  seen  and  felt.  The  granulations  and  abscess 
were  epidural.  The  paralysis  disappeared  in  a  few  days.  In  a 
month  the  patient  left  the  bed  and  commenced  to  walk.  How- 
ever, the  improvement  was  of  short  duration ;  the  paralysis  soon 
returned,  and  death  resulted  from  pulmonary  phthisis  in  seven 
months.  The  necropsy  revealed  tuberculosis  of  one  of  the 
bodies  of  the  dorsal  vertebrae  and  compression  of  the  cord  by  its 
lower  edge. 

In  the  second  case,  a  man  aged  33  years,  the  disease  com- 
menced with  a  violent  pain  between  the  second  and  fifth  dorsal 
vertebrae,  radiating  toward  the  right  side,  followed  by  paraplegia, 
incontinence  of  bladder,  rectum,  and  decubitus.  No  kyphosis, 
but  an  abscess  formed  on  the  right  side  of  the  spine.  Abscess 
opened  and  scraped.  Resection  of  second,  third,  and  fourth 
arches  of  dorsal  vertebrae.  No  improvement,  and  death  in 
eight  weeks.  Post-mortem  examination  revealed  more  exten- 
sive disease  than  was  found  at  the  time  of  operation.  Massive 
granulations  and  head  of  fourth  rib  on  right  side  encased  by  a 
tubercular  abscess.  From  here  the  disease  had  extended  into 
the  vertebral  canal  through  the  intervertebral  foramina. 

The  third  and  fourth  cases  had  some  essential  points  in 
common.  Their  ages  12  and  14  years  ;  gibbosities  at  the  same 
place;  paralysis  developed  with  root  symptoms.  Rest  in  recum- 
bent position  was  not  followed  by  any  improvement.  Resection 
of  the  arches  of  the  third  and  fourth  dorsal  vertebrae.  Tubercu- 


382  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

lar  pachymeningitis  occupied  the  space  exposed.  The  fungous 
granulations  were  removed  with  the  sharp  spoon,  and  at  the 
same  time  minute  tubercular  sequestra  were  removed.  In  one 
of  these  cases  prompt  improvement  of  all  the  symptoms  followed 
the  operation.  Sensation  returned  at  once,  and  motion  was 
restored  gradually.  In  about  two  months  the  paralysis  had 
practically  subsided.  After  a  short  period  the  paralysis  returned 
and  the  wound,  which  had  healed,  reopened,  and  another  curet- 
ting proved  likewise  a  failure.  The  patient  was  still  living  at 
the  time  the  report  was  made.  In  the  other  case  the  improvement 
was  slower,  but  equally  decisive.  At  the  end  of  a  week  the  boy 
could  lift  and  move  the  lower  extremities.  The  improvement 
continued  for  about  a  month,  when  the  symptoms  became  aggra- 
vated, and  subsequently  the  symptoms  varied  very  much,  but,  on 
the  whole,  the  patient  was  greatly  benefited  by  the  operation. 

Hoffa  (International  Journal  of  Surgery,  October,  1891) 
has  collected  thirteen  operations  within  the  vertebral  canal.  Two 
died  at  once,  two  recovered,  and  would  probably  have  done  so 
without  operation.  In  the  others  there  were  immediate  good 
results,  but  relapses  soon  occurred.  In  his  estimation,  lamnec- 
tomy  has  no  great  future  before  it,  and  should  be  limited  to 
those  cases  in  which  the  processes  alone  are  effected. 

De  Forest  Willard,  in  a  paper  entitled  "The  Operative 
Treatment  of  Tuberculous  Caries  of  the  Spine,"  read  at  the 
second  meeting  of  the  American  Congress  of  Physicians  and 
Surgeons,  expresses  himself  in  a  very  guarded  manner  in  refer- 
ence to  laminectomy.  He  maintains  that  for  the  relief  of  pressure- 
paralysis  the  laminae  are  to  be  removed  only  after  a  thorough 
trial  and  failure  of  long-continued  horizontal  extension,  counter- 
extension,  and  fixation.  In  the  majority  of  cases  recovery  takes 
place  after  extension  and  mechanical  treatment.  He  regards 
laminectomy  as  a  difficult  operation,  except  in  the  upper  dorsal 
region,  and  one  that  is  entailed  by  considerable  risk  to  life.  In 
caries  of  the  arches,  and  when  the  cord  is  compressed  from 
behind,  the  operation  is  justifiable  and  promises  good  results. 


TUBERCULOSIS  OF  THE  BONES  OF  THE  TRUNK.       383 

When  the  pressure  is  anterior,  either  from  the  deposit  of  caseous 
material  from  tubercular  infiltration  or  from  inflammatory  de- 
posit, no  permanent  benefit  will  be  secured,  even  though  tem- 
porary gain  is  apparent.  White,  in  his  recent  valuable  paper  on 
"  Spinal  Surgery  "  (Therapeutic  Gazette,  October,  1891),  gives 
the  analysis  of  forty  cases  of  this  operation  for  tubercular  spondy- 
litis,  which  are  all  the  author  was  able  to  bring  together.  Of  this 
number  twenty-two  were  either  materially  improved  or  absolutely 
cured.  The  unsuccessful  cases  which  recovered  from  the  oper- 
ation were,  in  some  instances,  the  subject  of  secondary  disease. 
The  deaths  were  twelve  in  number,  showing  a  mortality  of 
30  per  cent.,  and  were  due  to  various  causes,  such  as  shock, 
or  extensive  renal  and  pulmonary  disease.  In  others,  death 
was  directly  due  to  the  gravity  of  the  disease  of  the  cord. 

Mr.  Arbuthnot  Lane  (British  Medical  Journal,  October 
31,  1891)  is  a  strong  supporter  of  lamnectomy  in  the  treatment 
of  tubercular  spondylitis  complicated  by  paraplegia.  He  re- 
cently reported  eleven  cases,  in  which  this  operation  had  been 
performed  by  himself,  to  the  London  Clinical  Society.  In  all 
but  one  case  the  cord  was  found  compressed  by  an  abscess.  He 
is  of  the  opinion  that  several  of  the  cases  would  have  died  from 
secondary  lesions  without  the  operation.  Only  in  one  case  was 
death  attributable  to  the  operation,  and  this  was  a  child  in  a 
very  feeble  condition.  Only  in  one  case  was  the  subsequent 
formation  of  tubercular  material  so  rapid  as  to  obliterate  very 
quickly  the  benefit  derived  from  the  two  operations.  In  most  of 
the  cases  the  cord  was  compressed  about  the  level  of  the  fifth 
or  sixth  dorsal  vertebra.  From  his  experience  he  is  satisfied 
that  operative  interference  involved  very  slight  risk ;  it  was 
followed  by  very  little  pain;  it  relieved  the  patient  of  the  com- 
pression symptoms,  and,  lastly,  it  enabled  the  surgeon  to  treat 
the  diseased  vertebra  directly, — not  only  by  spooning,  irriga- 
tion, and  the  thorough  removal  of  all  carious  bone,  but  also  by 
the  repeated  local  application  of  iodoform,  from  which  he  be- 
lieved he  had  pbtained  the  greatest  benefit,  At  the  same 


384  TUBERCULOSIS  .OF    THE    BONES    AND    JOINTS. 

meeting  Mr.  Bowlby  said  that,  in  a  case  which  he  had  sub- 
mitted to  operation  two  years  ago,  no  pus  was  found,  but  the 
patient  made  a  rapid  recovery,  although  before  operation  he  had 
been  kept  quiet  for  a  long  time  without  improvement.  In 
another  case,  done  six  weeks  ago,  in  which  no  pus  was  found 
and  not  much  benefit  was  anticipated,  the  patient  had  begun  a 
week  subsequently  to  move  the  foot,  and  now,  after  six  weeks, 
the  paraplegia  was  greatly  relieved;  the  spine,  however,  was 
growing  more  bent.  He  did  not  believe  that  diseased  tissue  of 
the  bodies  of  the  affected  vertebrae  could  be  removed  to  any 
considerable  extent,  as  the  roots  of  the  nerves  and  other  parts 
intervened  between  the  site  of  operation  and  the  real  disease. 
The  utility  of  lamnectomy  in  the  treatment  of  spondylitic  para- 
plegia can  only  be  determined  by  a  more  careful  study  and 
comparison  of  cases  that  recover  spontaneously,  and  more  ex- 
tensive statistics  of  the  immediate  and  functional  results  follow- 
ing the  operation.  It  is  evident  that  one  of  the  indications  of 
the  operation  is  to  remove  the  tubercular  material  as  thoroughly 
as  possible,  more  especially  if  the  disease  has  extended  to  the 
meninges  of  the  cord.  More  frequently  than  has  been  hereto- 
fore supposed  these  are  implicated,  and  should  receive  proper 
attention  after  removal  of  a  sufficient  number  of  the  vertebral 
arches. 


CHAPTER  XXXIII. 

TUBERCULOSIS  OF  PELVIC  BONES,  SCAPULA,  CLAVICLE,  STERNUM, 

AND  RIBS. 

Pelvic  Bones. — Tuberculosis  of  the  pelvic  bones  has,  for 
well-founded  reasons,  always  been  regarded  as  a  serious  affection. 
Terrillon  (Medical  and  Surgical  Reporter,  February  25,  1888) 
points  out  the  fact  that  in  early  life,  up  to  about  30  years,  in 
tuberculosis  of  the  ilium,  the  disease  is  always  located  at  the 
centre  of  the  bone,  in  or  around  the  cotyloid  cavity ;  while  in 
older  patients  it  develops  in  the  peripheral  parts,  near  .the 
secondary  centres  of  ossification.  He  urges  early  operative 
treatment  to  prevent  involvement  of  large  areas  and  the  burrow- 
ing of  pus,  which  he  has  seen  travel  as  far  as  the  neighborhood 
of  the  popliteal  space.  If  the  disease  is  extensive,  the  suppu- 
rating channels  should  be  freely  laid  open  and  as  much  bone 
removed  as  is  diseased  or  can  be  taken  away  with  safety.  In 
the  event  a  tubercular  focus  is  located  near  the  acetabulum,  an 
early  operation  would  most  effectually  prevent  secondary  infec- 
tion of  the  hip-joint.  The  crest  of  the  ilium  is  quite  frequently 
the  seat  of  tubercular  inflammation,  and  the  operative  treatment 
will  often  require  quite  an  extensive  resection  of  this  part  of  the 
bone. 

In  the  case  of  a  girl  20  years  of  age,  suffering  from  a  long- 
standing fistula  over  the  pubic  symphysis,  I  found  a  tubercular 
focus,  nearly  the  size  of  a  walnut,  between  the  pubic  bones.  The 
cartilage  was  almost  completely  destroyed.  The  cavity  was 
thoroughly  scraped  out  and  packed  with  decalcified  iodolbrm- 
ized  bone-chips,  and  healed  in  a  short  time  without  suppuration. 
Thiery  (loc.  cit.,  p.  464)  gives  an  account  of  three  partial  resec- 
tions of  the  sacrum  for  tubercular  affections,  in  patients  24, 
26,  and  36  years  of  age,  respectively.  One  of  these  died  of 
erysipelas  eight  months  after  the  operation,  a  sinus  still  remain- 
ing ;  one  died  of  phthisis  two  years  later ;  the  last  case  was 

25  (385) 


386 


TUBERCULOSIS   OF    THE    BONES    AND    JOINTS. 


paraplegic,  but  could  walk,  by  the  aid  of  two  sticks,  six  months 
after  operation;  no  later  information.  The  anterior  surface  of 
the  sacrum  is  so  inaccessible  to  operative  treatment  that  when 
the  disease  is  located  here  it  would  be  better  to  rely  on  curet- 
ting and  injections  of  iodoform  or  balsam  of  Peru  than  under- 
take a  formidable  operation.  If  the  disease  involve  the  posterior 
surface,  radical  operation  should  be  attempted  if  mere  expectant 

treatment  has  failed. 

Heath  ("  Clinical  Lecture 
on  Sacro-Iliac  Disease."  Brit. 
Medical  Journal,  December 
16,  1876)  reports  three  cases 
of  tuberculosis  of  the  sacro- 
iliac  synchondrosis,  and  in  all 
of  them  the  process  terminated 
in  the  formation  of  an  ab- 
scess. The  abscess  was  evac- 
uated by  aspiration,  and  two 
cases  recovered,  while  the 
third  remained  under  observa- 
tion. He  advises  immobiliza- 
tion by  a  bandage  composed 
of  two  compresses  which  are 
placed  over  the  os  pubes, 
from  which  circular  belts  pass  around  the  pelvis  which  press 
the  diseased  surfaces  against  each  other. 

Through  the  writings  of  W.  Van  Hook  (u  Tuberculosis  of 
the  Sacro-Iliac  Joint."  Annals  of  Surgery,  vol.  viii,  pp.  401- 
433,  and  vol.  ix,  pp.  35-54  and  150-180)  and  Hektoen  ("Tu- 
berculosis of  Sacro-Iliac  Joint."  North  American  Practitioner, 
1890)  the  attention  of  surgeons  has  been  called  to  the  feasibility 
of  attacking  the  sacro-iliac  joint  in  the  treatment  of  tubercular 
affections  in  this  locality.  This  joint  is  quite  frequently  the 
seat  of  tubercular  inflammation,  and  after  sinuses  have  formed 
a  radical  operation  is  indicated,  provided  the  general  condition 


FIG.  52.—  SACRO-ILIAC  DISEASE.  ROPE  OF 
OAKUM  PASSED  THROUGH  SINUS  WHOLE 
LENGTH  OF  JOINT.  (Sayre.) 


TUBERCULOSIS   OF    PELVIC    BONES,    ETC. 

of  the  patient  warrants  such  a  procedure.  Abscesses  communi- 
cating with  this  joint  can  he  treated  hy  tapping  and  iodoform 
injections,  with  a  good  prospect  of  effecting  a  permanent  cure. 
Years  ago  Sayre  resorted  to  thorough  drainage  in  such  cases. 
For  this  purpose  he  used  a  rope  of  oakum  saturated  with  balsam 
of  Peru.  (Figs.  52  and  53.) 

This  case  made  an  excellent  and  permanent  recovery.  If 
an  operation  is  determined  upon,  the  sacro-iliac  synchondrosis 
must  be  exposed  by  a  large  incision  parallel  to  and  directly  over 
this  joint,  and,  with  chisel  and  hammer,  sufficient  bone  removed 
from  each  side  to  expose  the  tubercular  focus  freely,  which  is 


FIG.  53.— SAME  CASE.    SINUSES  IN  PERINEUM  DRAINED  IN  SAME  MANNER.    (Sayre.) 

then  removed  thoroughly  with  the  sharp  spoon.  lodoform- 
gauze  tamponade  and  secondary  suturing  should  take  the  place 
of  primary  suturing  and  tubular  drainage. 

Clavicle. — Tuberculosis  of  the  clavicle  is  quite  rare.  The 
peripheral  or  periosteal  form  occurs,  like  a  similar  affection  of 
the  malar  bone,  in  the  shape  of  small,  circumscribed,  tubercular 
abscesses,  with  or  without  sequestration.  Central  tubercular 
osteomyelitis  is  very  rare,  and  appears  either  as  a  diffuse  infil- 
tration, single  or  multiple  foci.  The  diffuse  form  and  multiple 
foci  may  render  complete  extirpation  of  the  bone  necessary. 
Two  such  cases  were  operated  on  successfully,  by  complete 


388  TUBERCULOSIS    OF    THE    BONES    AND    JOINTS. 

extirpation  of  the  bone,  in  the  clinic  at  Halle,  with  good 
result.  More  frequently  than  the  shaft  of  the  bone,  the  stern  o- 
clavicular  articulation  is  affected.  The  disease  appears  here,  as 
in  other  joints,  either  as  a  primary  disease  of  the  synovial  mem- 
brane or  the  joint  affection  develops  in  consequence  of  the 
extension  of  an  osseous  focus  in  the  manubrium  of  the  sternum 
or  the  sternal  end  of  the  clavicle  into  the  joint,  when  the  usual 
symptoms  of  tumor  albus  appear  in  succession.  From  a  diag- 
nostic point  it  is  important  to  remember  that  syphilitic  affec- 
tions of  this  joint  are  quite  frequent,  and  closely  simulate  the 
clinical  picture  now  under  consideration.  Tuberculosis  of  this 
joint  is  more  frequently  met  with  in  adults  than  children,  and 
not  infrequently  it  attacks  persons  advanced  in  years.  The 
oldest  subject  of  this  affection  that  has  come  under  my  notice 
was  a  woman,  72  years  old,  who  gave  no  history  of  heredity. 
Six  months  before  I  examined  her  the  lymphatic  glands  on  left 
side  of  the  neck  became  successively  enlarged,  followed  later  by 
caseation  and  formation  of  tubercular  abscesses.  About  the 
same  time  the  stern o-clavicular  joint  on  the  same  side  became 
tender,  painful,  and  swollen,  and  terminated  later  in  the  forma- 
tion of  a  large,  cold  abscess.  This  opened  at  two  places  in  the 
course  of  a  few  weeks.  Through  the  fistulous  tracts  a  probe 
could  be  introduced  into  the  joint  and  came  in  contact  with  the 
articular  surfaces,  denuded  of  their  cartilage.  Superficial  foci 
of  the  shaft  of  the  bone  are  easily  and  thoroughly  removed  by 
incision  and  scraping.  If  the  bone  contain  multiple  foci,  or  is 
diffusely  infiltrated  with  tubercle  or  cheesy  material,  extirpation 
of  the  entire  bone  should  be  resorted  to  as  soon  as  possible, 
before  the  disease  has  passed  much  beyond  the  loose  connective 
tissue  underneath  the  bone.  Tuberculosis  of  the  sterno-articular 
articulation  is  treated  upon  the  same  general  principles  as  simi- 
lar affections  in  other  accessible  joints.  Injection  of  iodoform 
or  balsam-of-Peru  emulsion  should  receive  a  fair  trial  before  the 
resulting  tubercular  abscess  has  opened  or  is  to  be  opened  for 
the  purpose  of  making  a  radical  operation.  If  a  tubercular 


TUBERCULOSIS   OF   PELVIC   BONES,    ETC.  389 

abscess  originating  in  this  joint  has  opened  and  has  left  a  fistu- 
lous  tract,  resection  of  the  joint  should  be  no  longer  postponed. 
I  resected  this  joint  successfully  in  one  case  of  long-standing 
tuberculosis,  where  a  number  of  fistulous  openings  led  into  the 
articulation,  which  was  extensively  destroyed  by  the  disease. 
The  sternal  end  of  the  clavicle  was  detached  from  the  surround- 
ing soft  parts,  and  divided,  with  a  metacarpal  saw,  about  two 
inches  from  the  articular  surface.  The  section  of  the  bone  was 
made  after  inserting  an  elevator  underneath.  The  articular 
surface  on  the  sternal  side  was  removed  with  chisel  and  sharp 
spoon.  In  another  somewhat  similar  case  the  operation  proved 
a  failure,  because  the  disease  had  already  extended  far  under- 
neath the  sternum  and  the  cartilages  of  the  ribs  on  the  same 
side.  Resection  of  the  sterno-clavicular  joint  was  performed  for 
the  first  time  for  caries  (tuberculosis)  by  Wut^er  in  1833,  but 
as  the  disease  extended  later  to  the  remaining  portion  of  the 
bone  he  had  to  remove  the  entire  bone  subsequently.  Velpeau 
removed  the  acromial  end  of  the  clavicle  for  caries  in  1828,  and 
this  operation  was  repeated  by  Roux  in  1834.  Meyer  removed 
the  entire  bone  for  rheumatic  (?)  caries  in  1823. 

Scapula. — Tuberculosis  of  the  scapula  is  usually  met  with 
in  patients  suffering  at  the  same  time  from  tubercular  affections 
of  other  bones.  It  occurs  either  as  a  superficial  granulating 
lesion,  producing  superficial  caries,  or  it  gives  rise  to  more 
extensive  necrosis.  The  superficial  lesions  attack  most  fre- 
quently the  spine  and  borders  of  the  bone,  while  necrosis  takes 
place  more  frequently  if  the  disease  is  more  centrally  located. 
A  number  of  cases  have  come  under  my  observation  where 
multiple  fistulous  openings  led  down  to  the  external  surface  of 
the  bone,  at  the  bottom  of  which  carious  bone  could  be  detected. 
Extensive  incisions  in  the  direction  of  the  subcutaneous  tracts 
always  disclose  a  number  of  distinct  superficial  foci,  which  could 
be  readily  removed  with  the  sharp  spoon.  A  repetition  of  the 
scraping  usually  resulted  in  a  final  cure.  Boeckel  reports  three 
operations  on  the  scapula  for  tuberculosis.  In  one,  a  woman 


390  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

40  years  old,  the  entire  scapula  was  removed,  and  the  patient 
remained  well  six  and  a  half  years  after  the  operation,  and  the 
arm  was  useful  In  the  remaining;  two  cases  partial  resection 
was  made,  with  favorable  result  and  good  use  of  the  arm.  In 
one  case  I  resected  the  knee-joint,  in  a  young  woman,  for  long- 
standing osteo-arthritis,  and  the  wound  healed  by  primary  union, 
and  the  patient  enjoyed  excellent  health  for  a  year  and  a  half, 
when  a  rather  acute  inflammation  of  the  shoulder-joint  set  in, 
with  implication  of  the  upper  portion  of  the  humerus.  Resec- 
tion of  the  shoulder-joint  was  made,  but  the  wound  never  healed, 
and  the  disease  in  the  shaft  of  the  humerus  extended.  When 
I  saw  her  again,  two  years  after  the  first  operation,  she  was 
emaciated  to  a  skeleton.  A  number  of  nstulous  openings  led 
into  the  resected  shoulder-joint  and  the  diseased  shaft  of  the 
humerus.  The  elbow-joint  was  also  extensively  diseased.  The 
spine  and  outer  surface  of  the  scapula  were  the  seat  of  exten- 
sive caries.  At  the  urgent  request  of  the  patient,  the  scapula, 
clavicle,  and  arm  were  removed,  and,  although  the  patient  did 
not  lose  more  than  half  an  ounce  of  blood  during  the  operation, 
she  never  rallied  from  the  immediate  effects  of  the  operation, 
and  died  twelve  hours  later. 

Jager  (Ried,  "  Die  Resectionen  der  Knochen,"  etc.,  p.  283. 
Niirnberg,  1847)  resected  almost  the  entire  scapula  for  a  tu- 
bercular affection  in  a  girl  8  years  old.  The  disease  appeared 
after  amputation  of  the  arm  for 'tuberculosis  of  the  elbow-joint. 
Only  the  glenoid  cavity  and  acromian  process  remained.  The 
disease  returned  in  this  part  of  the  bone  and  in  other  parts  of 
the  skeleton,  and  the  child  died  nine  months  after  the  operation. 
Experience  seems  to  show  that  when  tuberculosis  of  the  scapula 
presents  itself  as  an  isolated  aifection,  in  a  patient  otherwise 
healthy,  a  radical  operation  can  be  undertaken  with  a  good 
prospect  of  success,  even  if  the  lesion  is  quite  extensive ;  but 
that  when  the  disease  is  complicated  by  similar  affections  in 
other  bones  or  organs  a  radical  operation  is  contra-indicated. 
Sinuses  leading  down  to  diseased  bone  should  be  freely  laid 


TUBERCULOSIS   OP   PELVIC   BONES,   ETC.  391 

Open  and  scraped,  and  the  wound  packed  with  iodoform  gauze 
or  sterilized  gauze  moistened  with  a  50-per-cent.  emulsion  of 
balsam  of  Peru,  and  suturing  postponed  until  the  entire  surface 
of  the  wound  is  covered  with  vigorous  granulations. 

Sternum.-~ The  primary  starting-point  of  tuberculosis  of 
the  sternum  is  almost  always  in  the  interior  of  the  bone.  The 
upper  portion,  or  manubrium,  is  the  favorite  seat  for  the  disease 
in  this  bone.  Not  infrequently  both  sterno-clavicular  joints  are 
invaded  later.  The  disease  seldom  leads  to  sequestration,  but 
appears  as  caseous  foci  which  often  communicate  with  both  sur- 
faces of  the  bone.  It  attacks  more  frequently  young  adults 
than  children.  Partial  resection  of  the  sternum  for  caries  was 
first  done  by  Gallen.  Moreau  removed  a  portion  of  the  sternum 
and  the  cartilages  of  two  ribs,  and  Cittadini  performed  the 
operation  for  the  same  indication.  Boyer  removed  more  than 
one-third  of  the  middle  portion  of  the  sternum,  using  the  chisel 
and  small  saw  and  dividing  the  cartilage  with  a  knife.  It  is 
reported  that  Genouville  made  a  similar  operation.  Blandin 
resected  two  inches  of  the  sternum  with  the  cartilages  of  two 
ribs.  Boeckel  made  partial  resection  of  the  sternum  in  two 
cases,  in  patients  12  and  18  years  of  age,  and  in  both  instances 
the  operation  proved  a  success.  A  very  extensive  resection  of 
the  sternum  for  tuberculosis  was  made  by  Bessel-Hagen. 
("Ueber  eine  sehr  ausgedehnte  Resection  des  Manubrium  Sterni 
wegen  Caries."  Centralblat  f.  Chirurgie,  p.  902,  No.  50,  1889.) 
Ohlendorf  ("  Em  Fall  von  Resectio  Sterni."  Dissertation. 
Wiirzburg,  1884)  describes  a  case  of  resection  of  the  sternum 
for  tuberculosis  of  this  bone.  The  patient  was  a  woman,  38 
years  old,  who  was  suffering  from  a  swelling  of  the  sternum  for 
a  year.  On  the  left  side,  on  a  level  with  the  third  rib,  was  a 
fistnlous  opening  which  led  between  the  cartilages  of  the  second 
and  third  ribs,  behind  the  sternum,  into  an  abscess-cavity.  The 
fistulous  tract  was  laid  open  and  the  granulations  scraped  out. 
The  symptoms,  however,  became  aggravated  and  suppuration 
more  profuse.  The  sternum  and  second  and  third  ribs  on  left 


392  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

side  were  exposed  by  dissecting  up  the  skin  in  the  shape  of  a 
flap.  The  cartilages  of  the  exposed  ribs  and  sternum,  as  far  as 
its  middle,  were  removed  with  the  chisel  and  a  large  quantity 
of  caseous  pas  escaped.  The  post-sternal  abscess  was  now  freely 
exposed  and  the  fungous  granulations  were  scraped  out  with  a 
sharp  spoon.  The  wound  was  closed  with  sutures  and  was 
nearly  healed  at  the  end  of  eight  months,  only  a  minute  fistu- 
lous  opening  remaining.  One  of  the  most  striking  cases  illus- 
trating the  benefits  which  are  often  derived  by  heroic  measures 
in  the  treatment  of  tuberculosis  was  reported  by  Le  Dentu  to 
the  French  Congress  of  Tuberculosis.  A  man  suffering  from 
extensive  tubercular  lesions  in  the  second  stage,  involving  both 
lungs,  was  also  the  subject  of  extensive  tubercular  disease  of 
the  sternum.  The  general  condition  of  the  patient  was  so  grave 
that  the  surgeon  hesitated  to  perform  the  operation.  As  the 
patient  requested  urgently  surgical  interference,  Le  Dentu  re- 
moved, November  14,  1886,  nine  centimetres  of  the  sternum, 
together  with  two  to  three  centimetres  of  the  second,  third,  and 
fourth  ribs  on  each  side,  and  curetted  the  enormous  tubercular 
abscess  of  the  anterior  mediastinum  underneath  the  bones  re- 
moved. The  patient  not  only  survived  the  operation,  but  the 
wound  healed  in  six  months,  the  pulmonary  symptoms  improved, 
and  three  years  after  the  operation  he  enjoyed  robust  health. 
Removal  of  the  manubrium  of  the  sternum  with  sections  of  ad- 
joining ribs  can  be  done  with  safety  if  the  bony  parts  to  be 
removed  are  undermined  by  a  tubercular  abscess,  as  the  thick 
abscess-membrane  shuts  out  the  anterior  mediastinum,  and  if 
ordinary  care  is  exercised  no  harm  is  inflicted  on  the  important 
organs  contained  in  this  space. 

In  one  case  of  tuberculosis  of  the  sternum  complicated  by 
extensive  tuberculosis  of  the  costal  cartilages  on  the  left  side,  I 
found  a  large  caseous  focus  near  the  centre  of  the  body  of  the 
sternum.  With  chisel  and  spoon  this  focus  was  removed,  leaving 
a  defect  at  least  an  inch  in  diameter  and  involving  the  whole  thick- 

o 

ness  of  the  bone ;  at  the  same  time  the  costal  cartilages  from  the 


TUBERCULOSIS   OP   PELVIC    BONES,    ETC.  393 

fourth  to  the  seventh  rib  were  resected.  Recovery  was  speedy 
and  so  far  (two  years)  has  proved  permanent. 

Ribs. — Tuberculosis  of  the  ribs  is  quite  a  frequent  affection, 
and  occurs  in  preference  in  persons  whose  general  health  is 
otherwise  impaired.  It  appears  either  as  a  superficial  granulat- 
ing focus  starting  in  the  periosteum  and  reaching  the  subjacent 
bone  by  extension,  or  as  a  primary  central  osseous  affection. 
Extensive  undermining  between  the  affected  rib  and  pleura  often 
takes  place,  giving  rise  to  large  peri-pleuritic  tubercular  abscesses. 
Tuberculosis  of  the  ribs  not  infrequently  results  in  the  formation 
of  a  tubercular  peri-pleuritic  abscess  in  case  the  infection  ex- 
tends in  the  direction  of  the  chest  instead  of  the  surface.  The 
following  case  of  this  kind  came  under  my  observation  recently. 
The  patient  was  a  young  man  without  hereditary  tendency  to 
tuberculosis.  During  an  attack  of  la  grippe  he  Avas  taken  with 
pain  in  the  left  side,  which  was  followed  in  a  few  months  by  the 
appearance  of  a  swelling  the  size  of  a  hen's  egg.  Local  appli- 
cations produced  no  effect,  and  the  swelling  gradually  increased 
in  size  until  the  time  I  examined  him,  when  it  had  attained 
the  size  of  a  large  orange.  With  the  appearance  of  the  swell- 
ing the  pain  disappeared.  The  swelling  was  located  in  the 
mammary  line,  over  the  eighth  and  ninth  ribs.  Area  of  dullness 
extended  beyond  the  base  of  the  swelling.  No  indications  of 
pulmonary  disease.  Patient  somewhat  anaemic  and  emaciated. 
Diagnosis :  Tuberculosis  of  one  or  more  ribs. 

The  abscess  was  opened  by  an  incision  parallel  to  the  ninth 
rib  and  about  eight  ounces  of  typical  tubercular  pus  was  evac- 
uated. Muscles  around  abscess-cavity  pale  and  cedematous. 
From  the  floor  of  the  abscess  a  fistula  led  to  a  point  behind  the 
cartilage  of  the  ninth  rib  into  a  tubercular  cavity.  The  same 
rib,  on  the  inner  surface  to  the  extent  of  four  inches,  was  de- 
nuded of  periosteum  and  was  carious.  Four  inches  of  the  rib 
and  its  cartilage  were  excised,  when  another  cavity  as  large  as  the 
external  abscess  was  revealed,  the  floor  of  which  was  the  pleura. 
Both  abscess-cavities  were  thoroughly  scraped  out  with  a  sharp 


394  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

spoon,  iodoformized  and  packed  with  iodoform  gauze.  In  four 
weeks  the  patient  left  the  hospital  much  improved  in  health  and 
the  wound  completely  healed.  The  disease  is  also  very  prone 
to  extend  to  the  costal  cartilage,  into  which  the  tubercular  gran- 
ulations penetrate  and  which  gradually  remove  the  cartilage. 
Tuberculosis  of  the  ribs  is  a  painless  affection,  and  patients 
suffering  from  it  often  only  seek  advice  after  the  formation  of  a 
large  tubercular  abscess.  Adults  are  attacked  more  frequently 
than  children.  It  is  a  disease  of  adults.  It  is  often  in  direct 
etiological  relationship  with  pulmonary  tuberculosis,  which  may 
originate  from  a  tubercular  focus  underneath  a  rib,  or  pulmonary 
tuberculosis  may  become  the  cause  of  the  periostitic  form  of 
rib  tuberculosis.  The  process  may  start  in  the  perichondrium, 
especially  in  children.  I  have  already  alluded  to  this  subject, 
and  cited  instances  in  the  chapter  an  tubercular  chondritis. 
When  the  disease  primarily  affects  the  cartilage,  it  starts  in  the 
perichondrium  and  extends  from  here  to  the  cartilage.  In  all 
specimens  of  this  kind  I  have  noticed  that  the  greatest  defect 
answers  to  the  service  of  the  cartilage.  Later,  extension  of  the 
disease  along  the  periosteum  leads  finally  to  the  bony  part  of  the 
rib.  In  the  following  case  the  disease  remained  limited  to  the  car- 
tilaginous structure.  The  patient  was  a  man  46  years  old,  and 
well  nourished.  After  an  attack  of  typhoid  fever,  eight  months 
ago,  he  experienced  an  intermitting  pain  in  the  left  side  at  a 
point  corresponding  with  the  seventh  and  eighth  ribs,  which 
radiated  in  the  direction  of  the  spine.  A  month  later  a  swelling 
formed  at  that  point  near  the  sternum,  which  gradually  increased 
in  size  until  he  was  admitted  into  the  Milwaukee  Hospital  for 
surgical  treatment.  The  swelling  at  this  time  covered  an  area 
about  four  inches  in  diameter.  Fluctuations  could  be  distinctly 
felt ;  base  of  swelling  surrounded  by  a  ring  of  indurated  tissue. 
No  rise  in  temperature.  Diagnosis  :  Tuberculosis  of  rib.  Oper- 
ation February  6,  1890.  An  oval  skin-flap  was  made  with  the 
convexity  directed  downward,  which  freely  uncovered  the  mus- 
cular tissue.  After  opening  of  the  abscess  two  fistulous  tracts 


TUBERCULOSIS  OF  PELVIC  BONES,  ETC. 

could  be  followed  leading  between  and  behind  the  cartilages  of 
the  seventh  and  eighth  ribs.  The  under  surface  of  both  carti- 
lages was  much  eroded,  perichondrium  thickened.  Both  carti- 
lages and  adjacent  portion  of  ribs  were  removed  and  the  abscess- 
cavity  thoroughly  scraped  out  and  iodoformized.  The  wound 
was  sutured  and  a  capillary  drain  of  catgut  introduced.  Primary 
union  throughout.  No  relapse.  General  health  improved. 
The  tubercular  affection  extends  along  the  same  rib,  or  a  number 
of  ribs  are  affected  simultaneously  or  in  rapid  succession.  The 
resulting  abscess  spreads  either  toward  the  skin  or  pleura,  and 
sometimes  the  abscess  appears  a  distance  from  its  starting-point. 
Scraping  operations,  as  a  rule,  prove  unsuccessful  in  these  cases, 
even  when  the  disease  has  a  periosteal  origin,  as  the  tubercular 
granulations  are  usually  more  copious  underneath  than  on  the 
outer  surface  of  the  rib.  If  the  disease,  before  an  abscess  has 
formed  and  opened,  does  not  yield  to  injections  of  iodoform  or 
balsam  of  Peru,  rib  resection  is  indicated.  The  frequent  re- 
lapses which  have  followed  this  operation  are  due  to  incomplete 
removal  of  tubercular  tissue.  The  fistulous  tracts  are  often 
very  small  and  difficult  to  follow.  It  is  necessary  in  nearly 
every  case  to  resect  the  entire  diameter  of  the  rib  and  to  remove 
a  sufficiently  long  section  to  completely  expose  the  para-perios- 
teal  granulations  or  abscess.  The  scraping  must  be  done  with  a 
large,  sharp  spoon  and  continued  until  perfectly  healthy  tissue 
is  reached.  If  more  than  one  rib  is  affected^  multiple  resection 
becomes  necessary. 

Tillmanns  ("Resektion  der  vorderen  linken  Thoraxwand 
und  zwar  der  Rippen  u.  der  Weichtheile  wegen  schwerer  Tuber- 
culose,"  etc.  Bericlit  der  Med.  Gesellscliaft  in  Leipzig)  resected 
the  anterior  wall  of  the  thorax  on  the  left  side,  including  the 
ribs  and  soft  parts,  for  extensive  tuberculosis,  exposing  com- 
pletely the  left  pleural  cavity,  which  was  filled  with  tubercular 
pus.  The  surface  was  later  covered  .with  large  skin  grafts,  and 
the  patient  made  a  satisfactory  recovery.  The  section  of  a  rib 
can  be  done  quickly  and  safely  with  a  strong  pair  of  bone 


396  TUBERCULOSIS   OP   THE   BONES   AND   JOINTS. 

forceps.  lodofbrm-gauze  tamponade  or  a  dressing  saturated 
with  balsam  of  Peru  should  be  employed  after  the  operation 
and  the  suturing  of  the  wound  postponed  until  the  wound 
throughout  is  covered  with  healthy  granulations.  Partial  resec- 
tion of  ribs  for  caries  appears  to  have  been  a  well-known  pro- 
cedure for  a  long  time,  as  Celsus  alludes  to  it  in  describing  this 
affection.  Galen  is  credited  with  having  performed  the  opera- 
tion. Fabricius  ab  Aquapendente  declared  the  operation  as 
impracticable.  Aymar,  Severinus,  and,  later,  Gooch  and  Ole- 
weltt  revived  the  operation.  During  the  early  part  of  the 
present  century  it  was  practiced  by  Percy,  Richerand,  Cittadini, 
Roux,  Velpeau,  Anthony,  Clot,  Fricke,  Warren,  Dixon,  Kara- 
wajew,  Spessa,  Jaquet,  and  Textor.  McDowell  resected,  in 
1828,  the  posterior  portion  of  the  sixth  and  seventh  ribs, 
disarticulating  them  from  the  vertebral  column. 

Extirpation  of  a  complete  rib  was  first  done  by  Fiori. 
Cittadini,  Anthony,  and  Velpeau  used  bone  forceps  for  making 
the  bone  section. 


CHAPTER  XXXIV. 

TUBERCULOSIS  OF  JOINTS  OF  UPPER  EXTREMITY. 

Shoulder- Joint. — Of  all  the  large  joints  the  shoulder-joint 
is  least  frequently  the  seat  of  tuberculosis.  The  disease,  as  a 
rule,  originates  in  the  head  of  the  humerus,  osseous  foci  in  the 
scapular  part  of  the  joint  being  exceedingly  rare.  Caries  sicca 
is  found  most  frequently  in  this  joint.  This  form  of  joint  tuber- 
culosis gradually  destroys  the  head  of  the  humerus  without  the 
formation  of  an  abscess,  and  the  joint,  instead  of  being  swollen, 
is  often  diminished  in  size  from  the  destruction  of  the  head  of 
the  bone  and  contraction  of  the  capsular  ligament. 

The  appearance  of  the  upper  extremity  of  the  humerus  is 
well  shown  in  the  illustration  on  page  398. 

The  transverse  section  of  the  humerus  below  the  tuberosi- 
ties  shows  the  concentric  atrophy  of  the  shaft  which  attends  this 
form  of  tuberculosis,  and  which  was  first  described  by  Volk- 
mann.  The  disease  is  met  with  in  young  persons  with  and 
without  tuberculosis  of  other  organs.  The  exciting  cause  can 
often  be  traced  to  a  trauma.  The  so-called  caries  carnosa 
(Konig)  also  occurs  in  this  joint,  and  consists  in  an  extension 
of  the  tubercular  process  from  the  joint  into  the  medullary 
cavity  of  the  shaft.  The  medullary  tissue  is  replaced  by  fleshy 
granulations,  through  which  tubercles  are  disseminated. 

The  early  detection  of  effusion  into  the  shoulder-joint  is 
difficult  owing  to  the  tense  capsular  ligament,  dense  fascia,  and 
deep  muscular  layers  which  cover  the  joint.  A  swelling  under 
the  deltoid  muscle  more  frequently  suggests  an  affection  of  the 
subdeltoid  bursa,  or  an  inflammatory  exudation  into  the  loose 
connective  tissue  underneath  the  muscle  than  distension  of  the 
capsule  of  the  joint.  Perforation  of  the  capsule  often  takes 
place  at  a  point  where  it  is  not  covered  by  muscles,  which  is 
the  case  at  the  lower  border  of  the  subscapular  muscle,  in  which 
event  the  abscess  presents  itself  in  the  axilla.  At  other  times 

(397) 


398 


TUBERCULOSIS    OF   THE    BONES    AND    JOINTS. 


the  contents  of  the  joint  escape  at  a  point  where  the  tendon  of 
the  biceps  passes  over  the  joint,  when  the  abscess  appears  under 
the  .deltoid  muscle.  More  frequently,  however,  the  abscess 
migrates  farther  and  presents  itself  in  the  intermuscular  septa 

b. 


FIG.  54. — CARIES  SICCA  OF  SHOULDER-JOINT.    (Volkmann.) 

a,  b,  c,  different  stages  of  destruction  of  head  of  Uume.'us  ;    the  lines  mark  the  size  of  the  normal 
head  of  humerus.    K,  the  remnant  of  the  head  of  the  humerus. 

of  the  arm,  or  in  the  direction  of  the  scapula,  or  in  the  fossa 
subscapularis,  supra-  or  infra-  spinati,  or  underneath  the  pecto- 
ralis  major.  lodoform  injections  are  most  useful  in  the  synovial 
form  of  tuberculosis  of  the  shoulder-joint.  If  this  method  of 
treatment  is  resorted  to  in  caries  sicca,  it  is  necessary  to  com- 


TUBERCULOSIS   OF   JOINTS   OF    UPPER    EXTREMITY.  399 

bine  with  the  intra-articular,  parenchymatous  injections,  as  the 
capsule  of  the  affected  joint  is  always  thickened.  Caries  sicca, 
under  favorable  circumstances,  undergoes  a  spontaneous  cure  in 
from  two  to  three  years,  the  result  being  a  stiff  joint,  but  useful 
limb.  In  three  cases  of  caries  sicca,  in  which  Konig  made  re- 
section of  the  shoulder-joint,  the  operation  was  followed  by  acute 
miliary  tuberculosis.  If  the  disease  involves  at  the  same  time 
any  considerable  portion  of  the  shaft  of  the  humerus,  amputa- 
tion through  the  shoulder-joint  offers  the  only  prospect  of 
eradicating  the  disease  in  toto.  In  operations  of  this  kind  the 
glenoid  cavity  should  be  removed  completely  by  dividing  with 
the  saw  the  neck  of  the  scapula,  as  in  many  cases  of  amputation 
through  the  shoulder-joint  for  tuberculosis  the  disease  returned 
in  the  scapula,  and  in  some  of  these  cases,  at  least,  the  local  re- 
currence was  undoubtedly  due  to  incomplete  removal  of  diseased 
tissue  on  the  scapular  side. 

Resection  of  Shoulder- Joint. — This  operation  is  indicated 
in  the  treatment  of  tubercular  affections  of  the  shoulder-joint 
that  resist  intra-articular  and  parenchymatous  injections  of  iodo- 
form  or  balsam  of  Peru,  and  when  the  patient  does  not  suffer 
at  the  same  time  from  general  tuberculosis  or  tuberculosis  of 
other  organs  not  amenable  to  successful  surgical  treatment. 

History  of  Operation. — Boucher  removed  parts  of  the 
shoulder-joint  for  gunshot  wounds  in  1753,  and  Thomas  opened 
the  joint  for  the  extraction  of  necrosed  bone  in  1740.  The 
first  authenticated  case  of  intentional  resection  of  the  shoulder- 
joint  for  disease  was  done  by  Ch.  White  ("  Cases  in  Surgery," 
vol.  i)  in  1768.  The  patient  was  a  boy,  14  years  of  age,  who 
was  the  subject  of  an  acute  suppurative  inflammation  of  the 
shoulder-joint,  terminating  in  the  formation  of  an  extensive 
abscess,  which  had  discharged  itself  externally.  The  operation 
is  described  as  follows :  "  I  began  my  incision  at  that  orifice 
which  was  situated  just  below  the  processus  acromion,  and 
carried  it  down  to  the  middle  of  the  humerus.  by  which  all  the 
subjacent  bone  was  brought  into  view  •  then  took  hold  of  the 


400  TUBERCULOSIS   OF   THE    BONES    AND   JOINTS. 

patient's  elbow  and  easily  forced  the  upper  head  of  the  humerus 
out  of  its  socket,  and  brought  it  so  entirely  out  of  the  wound 
that  I  readily  grasped  the  whole  head  in  my  left  hand  and  held 
it  there  till  I  had  sawn  it  oft'  with  a  common  amputation  saw, 
having  first  applied  a  paste-board  card  betwixt  the  bone  and  the 
skin.  I  had  taken  the  precaution  of  placing  an  assistant,  on 
whom  I  could  depend,  with  a  compress  just  above  the  clavicle, 
to  stop  the  circulation  in  the  artery  if  I  should  have  the  misfor- 
tune to  cut  or  lacerate  it ;  but  no  accident  of  any  kind  hap- 
pened, and  the  patient  did  not  lose  more  than  two  ounces  of 
blood,  only  a  small  artery  which  partly  surrounds  the  joint 
being  wounded,  which  was  easily  secured."  The  patient  made 
a  good  recovery,  and  four  months  later  left  the  infirmary  com- 
pletely cured,  the  functional  result  being  excellent.  Sequestra- 
tion of  the  sawn  surface  of  the  humerus  delayed  the  healing  of 
the  wound.  Mr.  White's  example  was  followed  by  Mr.  Bent, 
of  Newcastle,  and  Mr.  Orred,  of  Cluster.  It  appears,  from  the 
accounts  we  have  of  these  operations,  that  the  disease  for  which 
they  were  performed  was  really  caries  of  the  shoulder,  and  that 
the  patients  retained  limbs  which,  if  not  perfect,  were  at  least 
extremely  useful.  Notwithstanding  this  encouragement  to 
extend  the  practice,  it  seems  to  have  been  afterward  treated  in 
England  with  entire  neglect.  In  France,  Moreau  the  elder  per- 
formed the  operation  successfully  in  1786,  and  the  army  sur- 
geons, particularly  Banus,  Percy,  and  Larrcy,  frequently 
resorted  to  it  on  account  of  recent  gunshot  wounds  instead 
of  removing  the  limb.  In  Scotland  the  operation  was  revived 
by  Mr.  Syme  in  1820,  and  was  later  performed  by  Babington, 
Listen,  Baddely,  Fergusson,  Lawrence,  Hunt.  Coote,  Hutchin- 
son,  Ericlison,  Birkett,  Stubbs,  Blackmann,  and  others.  In 
Germany  the  first  resection  of  the  shoulder  was  made  by 
Lentin  in  1771.  and  he  was  followed  by  Wutzer,  Fricke,  Jager, 
Blasius,  Textor,  Dictz,  Heyfelder,  Langenbeck,  Es march,  Wilms, 
and  Bartels.  Symes  says  ("  Treatise  on  the  Excision  of  Dis- 
eased Joints,"  p.  40,  1831):  "There  is  no  case  in  which  ex- 


TUBERCULOSIS    OF   JOINTS   0?!^-   EXTREMITY. 

'  ^7?  , 

'    '^  r 
cision  is  so  decidedly  preferable  to  amputation  as  caries  o 

shoulder-joint.  The  diseased  bone  can  here  be  readily  cut  away 
without  injury  to  any  important  organ,  and  the  object  gained  is 
no  less  than  the  preservation  of  the  whole  superior  extremity." 

Incision. — White  removed  the  head  of  the  humerus 
through  a  straight  incision  from  the  acromion  process  down- 
ward through  the  centre  of  the  deltoid  muscle.  The  same 
incision  was  practiced  by  Virgarrus.  The  incisions  of  Larrey, 
Kern,  Chassaignac,  and  Jager  are  only  slight  modifications  of 
White's  incision.  Baudens  commenced  his  incision  just  below 
the  coracoid  process  of  the  scapula  and  carried  the  knife  along 
the  groove  between  the  pectoralis  major  and  deltoid  muscles  to 
the  groove  for  the  biceps  muscle.  If  this  incision  did  not  afford 
the  necessary  room  for  the  removal  of  the  diseased  head  of  the 
humerus,  he  enlarged  the  wound  by  making  two  small  trans- 
verse cuts  (but  only  through  the  muscles)  in  a  forward  direction 
at  each  end  of  the  vertical  incision.  Baudens'  incision  was 
modified  by  Langenbeck,  Malgaigne,  and  Robert. 

Frank  and  Ried  joined  the  upper  end  of  the  vertical  in- 
cision by  a  short  transverse  cut  extending  beneath  the  acromion 
process.  Langenbeck  made  a  transverse  incision  which  crossed 
the  vertical  at  the  upper  end  at  each  side,  making  thus  a  T 
incision.  Bouzairies  joined  two  oblique  incisions  in  the  figure 
of  the  letter  V,  making  a  flap  with  the  base  directed  upward. 

Bent  made  a  long  incision  from  the  joint  downward  in  the 
furrow  between  the  pectoralis  major  and  deltoid  muscles ;  and, 
as  this  did  not  afford  enough  room,  he  made  two  short  trans- 
verse cuts,  the  one  meeting  the  upper  end  of  the  long  cut  divid- 
ing the  clavicular  attachment  of  the  deltoid  muscle,  the  lower 
the  humeral  insertion  of  the  pectoralis  major,  making  thus  a 
quadrangular  flap  with  the  base  directed  toward  the  body. 

Bell,  Morel,  and  Guepratte  made  a  semilunar  incision  witli 
the  base  directed  upward.  Wattmann  carried  the  knife  from 
the  posterior  margin  of  the  acromion  process  along  the  border 
of  the  deltoid  to  its  insertion,  and  joined  it  by  another  incision 


'A"A  J  •  -*- 

402          =\"\  '-.TUBERCULOSIS  OP  .THE   BONES    AND   JOINTS. 

\\At«  vv"    ,    ,  JVvW 

— » 'iV  V.  v 
extending  from  the  tip  of   the  coracoid    process   to   tlie  same 

point,  making  in  this  way  a  triangular  flap  which  included  the 
deltoid  muscle. 

Sabatier's  flap  incisions  are  the  same,  only  the  space 
included  by  the  incision  is  smaller.  The  older  Moreau  made  a 
quadrangular  flap  with  the  base  directed  downward,  while  a 
similar  flap,  witli  the  base  in  an  opposite  direction,  was  advised 
by  Manne,  Percy,  the  younger  Moreau,  Textor,  and  Jager. 

Syme  (loc.  cit.,  p.  50)  made  a  perpendicular  incision  from 
the  acromion  through  the  middle  of  the  deltoid,  nearly  to  its 
attachment,  and  then  another  one  upward  and  backward,  from 
the  lower  extremity  of  the  former,  so  as  to  divide  the  external 
part  of  the  muscle.  "  The  flap  thus  formed  being  dissected  oft', 
the  joint  will  be  brought  into  view,  and  the  capsular  ligament, 
if  still  remaining,  having  been  divided,  the  finger  of  the  surgeon 
may  be  passed  around  the  head  of  the  bone  so  as  to  feel  the 
attachments  of  the  spinati  and  scapular  muscles,  which  can  then 
be  readily  divided  by  introducing  the  scalpel  first  on  the  one 
side  and  then  on  the  other.  After  this,  the  elbow  being  pulled 
across  the  fore  part  of  the  chest,  the  head  of  the  humerus  will 
be  protruded,  and  may  then  be  easily  sawn  off  while  grasped  in 
the  operator's  left  hand."  Syme  described  one  of  his  operations 
of  resection  of  the  shoulder-joint  in  which  the  whole  operation, 
including  the  dressing,  occupied  only  ten  minutes. 

Albanese  (Virchow  u.  Hirsch's  "  Jahresbericht,"  1871, 
B.  ii,  p.  402)  makes  a  posterior  incision  in  the  shape  of  an 
inverted  L,  commencing  at  the  spine  of  the  scapula,  at  the 
junction  of  this  with  the  acromion  process,  extending  from 
above  downward  and  forward  to  the  head  of  the  humerus, 
from  where  it  is  directed  forward,  terminating  at  the  tubercu- 
lum  majus.  The  muscles  are  separated  with  the  periosteum, 
and  through  the  wound  the  head  of  the  humerus  is  removed. 
It  is  claimed  that  this  incision  has  the  advantage  over  other 
posterior  incisions,  as  it  does  not  endanger  the  circumflex  nerve. 

Modern  Operation. — The  incisions  that  are  now  practiced 


TUBERCULOSIS    OF   JOINTS   OF    UPPER    EXTREMITY. 


403 


in  resection  of  the  shoulder-joint  are  such  that  will  secure  free 
access  to  the  diseased  structures  without  injuring  any  of  the 
muscles  or  other  important  para-articular  structures.  Resec- 
tion for  tubercular  affections  of.  the  joint  requires  not  only  an 
incision  through  which  the  head  of  the  huraeras  can  be  dislo- 
cated and  removed,  but  it  must  be  made  in  such  a  locality  and 
in  such  a  manner  as  to  enable  the  operator  to  remove  the  dis- 
eased capsule  and  para-articular  tissues  and  as  much  as  neces- 
sary of  the  scapular  portion  of  the  joint.  Incision  through 
the  centre  of  the  deltoid,  detachment  of  important  muscles,  or 
transverse  incision  through 
them  is  strenuously  avoided, 
in  order  to  secure  a  satisfac- 
tory functional  result  by  the 
operation.  A  straight  ante- 
rior or  posterior  incision  is 
now  generally  selected  for 
typical  or  atypical  resection 
and  arthrectomy. 

The  anterior  incision  is 
commenced  at  a  point  half 
way  between  the  acromial 
end  of  the  clavicle  and  the 
coracoid  process,  and  is  car- 
ried directly  downward  six 
to  ten  centimetres,  dividing  all  the  tissues  down  to  the  joint. 
The  margins  of  the  wound  are  now  retracted,  the  long  head  of 
the  biceps  tendon  held  out  of  the  way,  and  the  anterior  surface 
of  the  joint  fully  exposed.  The  capsule  is  opened  by  making 
three  incisions,  which,  when  united,  give  the  appearance  of  a 
narrow  horseshoe:  £1.  The  first  vertical  cut  is  made  while  the 
arm  is  rotated  outward  through  the  inner  half  of  the  capsule, 
when  the  tendon  of  the  subscapular  muscle  is  attached.  The 
arm  is  then  rotated  inward  and  the  second  vertical  incision  made 
through  the  capsule  and  down  to  the  tendons  of  the  supra- 


FIG.  55.— RESECTION  OF  SHOULDER-JOINT. 
STRAIGHT  ANTERIOR  INCISION. 


404  TUBERCULOSIS   OF   THE    BONES    AND    JOINTS. 

spinatus,  infra-spinatus,  and  teres  minor  muscles;  tliese  two 
incisions  are  then  united  by  a  transverse  cut  through  the  upper 
portion  of  the  capsule.  Through  this  opening-  the  head  of  the 
humerus  can  be  readily  dislocated,  and,  after  separation  of  the 
posterior  portion  of  the  capsular  ligament,  the  diseased  part  of 
the  bone  is  removed  by  sawing  off  the  head  through  the  surgical 
or  anatomical  neck,  or  by  removing  foci  with  chisel  and  sharp 
spoon.  The  latter  procedure  is  especially  to  be  recommended  in 
performing  this  operation  on  children,  as  the  removal  of  the 
upper  epiphysis  in  such  cases  would  be  very  likely  to  result  in 
great  shortening  and  very  imperfect  restoration  of  function.  In 
children  atypical  resection  of  the  shoulder-joint  should  always 
be  done  if,  by  this  operation,  all  diseased  tissues  can  be  reached 
and  removed.  After  removal  of  all  osseous  foci  the  diseased 
capsule  is  extirpated  and  the  glenoid  cavity  carefully  examined 
and  thoroughly  dealt  with.  If  the  wound  is  packed  with  iodo- 
form  gauze  and  closed  later  by  secondary  suturing,  a  posterior 
counter-opening  for  drainage  is  unnecessary.  The  tendon  of 
the  biceps  muscle  and  the  circumflex  nerve  must  be  carefully 
protected  against  injury,  which  can  only  be  done  by  making- 
free  use  of  an  elevator  or  other  blunt  instrument  in  isolating 
and  dislocating  the  head  of  the  humerus.  Resection  of  the 
upper  end  of  the  humerus,  within  the  limits  of  the  surgical 
neck,  can  be  done  most  advantageously  through  a  posterior 
incision.  The  incision,  six  to  eight  centimetres  in  length, 
should  start  from  the  posterior  border  of  the  acromion  process, 
downward  through  the  posterior  portion  of  the  deltoid,  directly 
down  to  the  joint.  If  the  arm  is  kept  rotated  outward  the  in- 
cision falls  in  line  with  the  centre  of  the  great  tuberosity  of  the 
humerus.  The  muscles  and  periosteum  are  separated  from  the 
bone  while  the  arm  is  being  rotated  outward.  In  this  way  the 
other  side  of  the  bicipital  groove  is  reached,  when  the  tendon 
of  the  subsca  pular  muscle  is  detached.  The  arm  is  then  rotated 
more  and  more  inward,  when  the  muscles  inserted  posteriorly 
are  separated  with  the  periosteum  and  the  capsular  ligament. 


TUBERCULOSIS   OF   JOINTS   OF   UPPER    EXTREMITY. 


405 


Finally  the  arm  is  brought  forward  and  the  head  of  the  humerus 

dislocated  backward  and  partially  or  completely  removed.    After 

the  removal  of  all  osseous  foci  the  capsule  and  glenoid  cavity 

are  dealt  with  in  the  same  manner  as  in  making  the  anterior 

incision.     Arthrectomy  and  atypical  resection  of  the  shoulder- 

joint  could  be  done  most  readily  and  with  the  least  degree  of 

violence  to  the  soft  parts  surrounding  the  joint  by  temporary 

resection   of  the  acromion  process,  combined  with   a   straight 

anterior  or  posterior  inci- 

sion.     After    removal   of 

all  diseased  tissue  the  acro- 

mion process  could  be  su- 

tured in  its  normal  location 

with  catgut  or  silver-wire 

sutures.      This    operation 

will,  undoubtedly,  be  more 

perfected  and  will  be  fre- 

quently resorted  to  in  the 

future,    in    proper    cases. 

In  the  after-treatment  of 

resection  of  the  shoulder- 

joint  the  arm  should  be 

well  supported  and  immo- 

bilized in  such  a  manner 

thflt  thf1  nnnev  end  of  the 

' 

humerus    is    brought    in 

close  contact  with  the  glenoid  cavity  or  sawn  surface  of  the  neck 
of  the  scapula.  This  object  can  be  attained  to  the  greatest 
degree  of  perfection  by  padding  arm  and  forearm  with  absorbent 
cotton  and  bringing  the  forearm  across  the  chest,  slightly  ele- 
vated, and  encircling  the  whole  limb,  chest,  and  the  top  of  the 
opposite  shoulder  in  alight  plaster-of-Paris  dressing.  Passive 
motion  should  not  be  made  until  the  wound  has  healed  and  a 
sufficient  time  has  elapsed  for  the  formation  of  a  new  joint, 
which  will  require  from  four  to  six  weeks.  Active  use  of  the 


FIG.  56.  —  EXCISION  OF  SHOULDER-JOINT  AND  UP- 
PER  THIRD  OF  HUMERUS.  RESULT  TWENTY-FIVE 
YEARS  AFTER  OPERATION.  (Annals  of  Surgery.) 


406  TUBERCULOSIS  OF   THE  BONES   AND   JOINTS. 

arm  is  postponed  still  longer.  It  is  not  often  that  patients  can 
raise  the  arm  above  the  horizontal  position,  even  when  the  func- 
tional result  is  excellent.  Langenbeck  reported  a  case  of  exci- 
sion of  the  entire  shaft  of  the  humerus,  with  both  articular  ends, 
in  which  almost  complete  reproduction  of  the  bone  took  place, 
with  good  use  of  the  arm.  If  several  inches  of  the  bone  have 
to  be  removed,  and  reproduction  of  bone  does  not  take  place, 
the  arm  can  be  made  useful  by  the  use  of  a  proper  apparatus. 

The  muscular  atrophy,  which  is  often  present  to  a  marked 
degree,  is  to  be  treated  by  massage  and  the  use  of  the  interrupted 
current. 

Elbow-Joint. — Like  in  the  shoulder-joint,  tuberculosis  of 
the  elbow-joint  is  essentially  a  disease  of  young  adults,  and 
attacks  much  more  frequently  primarily  the  bones  than  the 
synovial  membrane.  In  frequency  the  osseous  form  appears 
first  in  the  olecranon,  where  it  is  often  met  with  in  the  form  of 
a  wedge-shaped,  necrotic  infarct ;  then  the  lower  end  of  the 
humerus,  the  head  of  the  radius  being  affected  only  in  excep- 
tional cases.  Konig  found,  in  62  resection  specimens  of  this 
joint,  that  the  disease  was  purely  synovial  in  10  and  osseous 
in  42 ;  of  these  42  cases  the  ulna,  more  especially  the  olecranon, 
was  the  primary  seat  in  22,  the  humerus  in  17,  the  humerus 
and  radius  together  in  21,  and  the  radius  in  one.  Middel- 
dorpf  found,  in  137  cases,  that  the  disease  was  primarily 
synovial  in  30  and  osseous  in  107.  Of  the  bones  the  ulna, 
chiefly  the  olecranon,  was  the  seat  primarily  in  49,  the  hu- 
merus in  33,  the  external  condyle  in  4,  the  humerus  and 
ulna  together  in  18,  the  radius  in  3,  all  of  the  bones  in  2, 
and  the  radius  and  ulna  in  2.  Primary  synovial  tubercu- 
losis was  more  frequent  in  persons  less  than  14  years  of  age 
than  afterward,  the  proportion  between  synovial  and  bone 
disease  in  childhood  bring  as  29.5  to  70.5.  Middeldorpf 
("  Weitere  Beitrage  zur  Resektion  des  Ellenbogen  Gelenkes." 
Archiv  /.  klin.  CJiirurgie,  B.  xxxiii.  p.  226)  is  of  the  opinion, 
from  a  clinical  study  of  a  large  number  of  cases  of  tuberculosis 


TUBERCULOSIS   OF   JOINTS   OF   UPPER   EXTREMITY.  407 

of  the  elbow-joint,  that  resection  is  indicated  in  about  73  per 
cent.  In  his  cases  the  right  arm  was  affected  in  57,  the  left  in 
38,  and  both  sides  in  53.  Fifty-three  were  males  and  46  females. 
The  largest  number  of  cases  were  between  20  and  25  years  old. 


FIG.  57.— TUBERCULOSIS  OF  THE  ELBOW-JOINT,  WITH  MARKED  ATROPHY 
OF  MUSCLE  OF  ARM  AND  FOREARM. 

The  synovial  form  was  represented  by  about  25  per  cent.  In 
nearly  75  per  cent,  osseous  foci  were  found  in  both  articular 
extremities. 

One  of  the  first  symptoms  which  points  to  the  existence 


408  TUBERCULOSIS   OF   THE    BONES    AND    JOINTS. 

of  tuberculosis  in  this  joint  is  limited  motion.  The  patient 
holds  the  arm  in  a  flexed  position,  and  is  unable  to  extend  it 
completely ;  at  the  same  time  the  forearm  gradually  assumes  a 
fixed,  pronated  position,  rotation  of  the  forearm  being  either 
entirely  absent  or  always  limited.  The  swelling,  which  at 
first  is  not  well  marked,  appears  first  over  the  radio-humeral 
joint  and  along  the  sides  of  the  olecranon,  in  localities  where 
the  joint  is  nearest  to  the  surface.  When  the  swelling  has  be- 
come extensive  it  assumes  a  spindle-shaped  form,  the  centre  of 
which  corresponds  to  the  joint,  from  which  it  tapers  gradually 
toward  the  arm  and  forearm.  This  peculiar  shape  of  the  arm 
becomes  more  marked  after  muscular  atrophy  is  far  advanced. 

Perforation  of  the  capsule  and  the  formation  of  para-artic- 
ular abscesses  occur  most  frequently  in  the  same  regions ;  but 
the  abscsses  often  wander  quite  a  distance  before  spontaneous 
perforation  takes  place,  so  that  it  is  often  difficult,  if  not  impos- 
sible, to  follow  the  fistulous  tracts  with  a  probe  into  the  joint. 
Infra-articular  injections  of  iodoform  can  be  made  by  entering 
the  joint  from  the  outer  aspect, -bet ween  the  head  of  the  radius 
and  the  external  condyle  of  the  humerus.  As  this  conservative 
treatment  is  often  followed  by  stiffness  or  false  or  even  bony 
ankylosis,  the  forearm  should  be  kept  in  the  most  favorable 
position  during  the  treatment,  in  the  event  that,  if  such  results 
follow,  the  limb  will  be  most  serviceable  to  the  patient.  This 
position  is  flexion  of  the  forearm  at  a  right  angle  with  the  arm, 
with  the  forearm  halfway  between  pronation  and  supination. 

Resection  and  Arthrectomy .  History  of  Operations. — The 
first  attempts  to  substitute  resection  of  the  elbow  for  amputation 
were  made  by  Bilguer,  who  extracted  fragments  of  bone  in  a 
compound  fracture  of  this  joint ;  and  Wainmann  and  Gorke, 
who  made  partial  resections,  the  former  for  compound  dislocation, 
the  latter  for  gunshot  wound.  The  original  idea  of  this  opera- 
tion proceeded  from  Mr.  Park,  of  Liverpool,  who  made  the  re- 
section on  the  dead  subject,  but,  for  what  reason  does  not 
appear,  he  never  applied  it  in  practice.  Park  made  the  opera- 


TUBERCULOSIS   OF   JOINTS   OF    UPPER    EXTREMITY.  409 

tion  on  the  cadaver  and  recommended  its  adoption  in  practice. 
The  elder  Moreau  made  the  first  complete  resection  of  the  elbow- 
joint  in  1794.  Percy,  Diipuytren,  and  Roux  followed  his  ex- 
ample when  the  operation  was  forgotten  in  France,  until  it  was 
revived  by  Chassaignac  and  Maisonneuve,  in  1850.  The  two 
Moreaus,  however,  adopted  it  in  good  earnest,  and  employed  it 
at  Bar-sur-Ornain  with  great  success.  Three  of  their  cases  are 
detailed  in  the  treatise  of  Moreau  junior,  and  two  others  are 
simply  mentioned  by  'him  in  which  the  result  was  equally  satis- 
factory, but,  the  patients  being  young  ladies,  the  particulars  are 
not  related.  In  England  it  was  introduced  by  Park  and  Syme. 
In  Germany  the  first  complete  resections  of  the  elbow-joint 
were  performed  by  Jager  and  Textor.  In  Italy  the  operation 
was  introduced  by  Mazzoza.  In  Russia,  by  Pirogoff,  Hiibbenet, 
Nemert,  and  the  two  Heyfelders.  In  America,  by  Smith,  Bauer, 
and  Carnochan. 

Incision. — Park  made  a  single,  straight,  posterior  incision, 
the  same  as  was  later  practiced  by  Chassaignac  and  Langenbeck. 
The  modifications  of  this  incision  have  been  various ;  thus,  the  »-j 
after  J.  F.  Heyfelder  and  Maisonneuve,  the  -|-  after  Park,  Lizars, 
and  Syme ;  the  I  after  Simon  ;  the  T  after  Thore,  Listen,  and 
Roux  ;  the  double  longitudinal  incision  after  JefFray.  Textor 
formed  a  posterior  triangular  flap  with  the  base  directed  down- 
ward, while  Guepratte  made  an  oval  flap  with  the  base  in  an 
opposite  direction.  Moreau  and  Dietz  preferred  a  single,  or,  if 
this  did  not  afford  enough  room,  a  double  H  quadrangular  flap. 

Modern  Operation. — The  most  serviceable  incision  is  the 
straight  posterior  made  directly  over  the  centre  of  the  olecranon 
process,  and  if  this  does  not  afford  ample  room  and  access  to 
every  part  of  the  joint  it  can  be  joined  by  a  short,  straight, 
transverse  incision  directly  over  the  radio-humeral  joint. 

If  the  articular  ends  of  all  of  the  three  bones  which  enter 
into  the  formation  of  this  joint  are  to  be  removed,  the  muscular 
attachments,  witli  the  periosteum  are  to  be  separated,  and  by 
forcible  flexion  of  the  arm  the  ends  are  rendered  accessible  and 


410 


TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 


are  sawn  off.  The  tendon  of  the  triceps  muscle  is  to  be  sutured 
to  the  upper  end  of  the  ulna  after  the  resection  has  been  com- 
pleted, and  the  arm  is  dressed  for  at  least  three  weeks  in  the 
extended  position.  In  liberating  the  lower  end  of  the  humerus 
extreme  care  must  be  exercised  in  protecting  the  ulnar  nerve 
against  injury.  This  is  best  done  by  lifting  it  out  of  its  groove 
behind  the  internal  condyle  of  the  humerus  with  the  perios- 
teum with  an  elevator,  and  keeping  it  out  of  the  way  by  a  blunt 


FIG.  58.— LANGENBECK'S  INCISION.  (Bryant.)       FIG.  59.— LISTON'S  INCISION.    (Bryant.) 

retractor,  as  advised  by  Langenbeck  in  the  description  of  his 
subperiosteal  resection  of  this  joint. 

Complete  resection  of  the  elbow-joint  is  seldom  required, 
and  the  chisel  is  gradually  taking  the  place  of  the  saw  in  ex- 
cision of  this  joint,  which,  in  the  majority  of  cases,  should  not 
be  complete,  but  partial. 

Temporary  Resection  of  Olecranon. — Partial  resection  of 
the  elbow-joint,  after  temporary  resection  of  the  olecranon,  can 
be  done  through  a  straight  posterior  incision  to  which,  if  need 
be,  short,  transverse  cuts  can  be  added  directly  over  the  joint  to 
answer  special  indications.  The  limb  should  always  be  rendered 


TUBERCULOSIS    OF   JOINTS   OF    UPPER    EXTREMITY.  411 

bloodless  by  elastic  constriction,  which  should  be  applied  at  a 
point  where  the  musculo-spiral  nerve  is  well  protected  by  mus- 
cles. Vogt  not  only  preserved  the  olecranon,  but  also  the  epicon- 
dyles  in  resection  of  the  elbow-joint. 

Of  the  many  cases  of  resection  of  the  elbow-joint  done  by 
myself,  the  following  have  been  selected  to  illustrate  the  differ- 
ent forms  of  tuberculosis  of  this  joint,  as  well  as  for  the  purpose 
of  showing  what  may  be  expected  from  this  operation,  if  an 
attempt  is  made  to  preserve  the  olecranon  process. 

Case  I.  Man  aged  48,  German,  tailor  by  occupation. 
Duration  of  disease  about  one  year.  Joint  swollen,  a  number 
of  fistulous  openings  communicating  with  it.  An  attack  of 
acute  para-articular  inflammation  commenced  two  weeks  ago, 
but  is  now  subsiding.  Operation  May  18,  1890.  Straight 
posterior  incision.  Complete  chisel  resection  of  joint  after 
temporary  resection  of  olecranon  process.  The  articular  surface 
of  the  ulna  contained  a  triangular  sequestrum  projecting  into 
the  joint.  After  removal  of  the  sequestrum  the  cavity  was 
thoroughly  scraped  out,  and,  after  disinfection  and  iodoformiza- 
tion,  the  wound  was  sutured  and  drained  with  a  catgut  drain. 
Olecranon  fastened  with  two  aseptic  ivory  nails.  Arm  dressed 
in  extended  position.  Patient  left  hospital  May  25th,  only  a 
very  small  sinus  remaining.  I  was  informed  later  that  the 
wound  healed  and  a  fair  degree  of  motion  of  joint  was  recov- 
ered, but  then  symptoms  of  pulmonary  tuberculosis  developed 
and  death  resulted  from  this  cause  a  year  later. 

Case  II.  Woman  48  years  old,  with  disease  of  right  elbow- 
joint  of  four  years'  duration.  An  abscess  communicating  with 
the  joint  opened  three  months  ago,  leaving  a  permanent  fistula. 
Operation  May  31,  1889.  Same  incision.  Disease  limited  to 
synovial  membrane,  capsule,  and  articular  surfaces  of  joint. 
Complete  chisel  resection  of  joint,  with  preservation  of  olecranon 
process.  Fixation  of  olecranon  process  with  two  chromicized 
catgut  sutures.  Primary  healing  of  entire  wound.  Fair  mo- 
tion of  joint,  and  after  six  months  good  use  of  arm.  No  local 


412  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

recurrence,  and  marked  improvement  of  general  health  of 
patient. 

Case  HI.  Male  18  years  old,  with  tubercular  family  history, 
the  subject  of  primary  synovial  tuberculosis  of  elbow-joint  for 
nine  -months,  was  subjected  to  resection  December  3,  1889. 
Temporary  resection  of  olecranon  process.  Extensive  synovial 
disease,  with  implication  of  articular  cartilages.  Atypical  resec- 
tion of  articular  ends.  Catgut  drain.  Primary  union  of 
wound.  At  the  end  of  four  months  useful  arm  and  about  half 
the  normal  range  of  motion.  No  local  recurrence  to  date. 

Giise  IV.  Tailor,  aged  44,  without  any  hereditary  tendency 
to  tuberculosis,  has  been  suffering  with  an  affection  of  the  right 
elbow-joint  for  five  years,  which  recently  has  prevented  him  from 
following  his  occupation.  Joint  greatly  swollen,  presenting  all 
the  typical  appearances  of  tuberculosis.  Posterior  straight  in- 
cision and  typical  chisel  resection  of  joint,  with  preservation  of 
olecranon.  A  number  of  rice-bodies  were  found  in  the  joint, 
with  great  thickening  of  synovial  membrane  and  capsule.  The 
soft  joint-structures  were  thoroughly  extirpated.  Olecranon 
nailed  to  shaft  of  ulna.  Primary  union  of  wound.  At  the  end 
of  three  months  patient  was  able  to  resume  his  occupation, 
having  nearly  the  normal  range  of  motion.  No  local  recurrence, 
and  general  health  greatly  improved. 

Bruns  recommended  osteoplastic  resection  of  the  elbow- 
joint  in  1858.  Mosetig-Moorhof  ("Ueber  osteoplastische  Re- 
section des  Ellenbogengelenkes."  Wiener  Med.  Presse,  pp.  825, 
857, 1883)  revived  Brims'  operation,  and  reports  three  successful 
cases.  The  olecranon  process,  if  not  the  seat  of  the  disease,  is 
sawn  through  at  its  junction  with  the  shaft  of  the  ulna,  and, 
after  resection  of  the  joint,  is  fastened  in  its  normal  place  with  a 
bone  suture  of  chromicized  catgut. 

Trendelenburg  ("Ueber  die  temporiire  Resection  des  Ole- 
cranon," etc.  CentralUatt  /.  Chirnrgie,  No.  52,  1880)  made 
the  first  temporary  resection  of  the  olecranon  in  March,  1878. 
He  exposes  the  process  by  a  flap,  the  convexity  of  which  is 


TUBERCULOSIS    OF   JOINTS    OF    UPPER    EXTREMITY.  413 

directed  upward.  The  olecranon  is  divided  at  its  junction  with 
the  shaft  of  the  ulna  with  a  chisel,  and  is  again  fastened  in  its 
place  with  two  metallic  (steel  wire)  sutures  after  the  completion 
of  the  operation  on  the  joint.  He  places  great  stress  on  the 
importance  of  making  the  external  incision  in  such  a  manner 
that  it  does  not  correspond  with  the  incision  through  the  bone 
and  into  the  joint,  so  that,  after  suturing  of  the  external  wound, 
the  deep  incisions  are  to  a  certain  degree  subcutaneous  injuries. 

vSpuhn  ("Ueber  die  Resection  des  Ellenbogengelenks." 
Dissertation,  Bonn,  1885)  reports  eighteen  cases  of  resection  of 
the  elbow-joint  from  the  clinic  at  Bonn,  of  which  twelve  were 
made  for  tubercular  disease  and  six  for  old  dislocations  and 
fractures.  The  method  employed  is  the  following:  A  trans- 
verse curved  incision  is  made  over  the  posterior  aspect  of  the 
joint  from  one  condyle  to  the  other,  with  the  base  directed 
upward.  The  short  flap  thus  made  is  dissected  away  from  the 
fascia  of  the  triceps  muscle  and  the  olecranon  process.  With 
dull  instruments  the  olecranon  process  is  isolated  from  the  soft 
parts  with  exclusion  of  the  periosteum.  After  careful  isolation 
of  the  ulnar  nerve  with  the  attached  soft  parts,  the  joint  is  in- 
cised along  the  inner  side  of  the  olecranon,  and  the  process 
divided  transversely  with  a  broad,  sharp  chisel.  This  exposes 
the  joint  freely,  and  through  the  wound  the  articular  ends  of 
the  bones  can  be  removed  and  the  capsule  extirpated.  After 
the  resection  the  olecranon  process  is  fixed  to  the  shaft  of  the 
ulna  in  its  former  position  by  means  of  a  silver-  or  iron-  wire 
suture,  and.  after  disinfection  of  the  wound,  is  sutured  and  care- 
fully drained,  and  the  limb  immobilized  in  a  paste-board  splint. 
The  functional  results  were  excellent. 

Pick  (London  Lancet,  October  2,  1886)  described  an  osteo- 
plastic  resection  of  the  elbow-joint  in  which  the  healthy  olecra- 
non process  was  cut  off  with  a  sharp  chisel  and  the  joint  thus 
opened.  After  removal  of  the  diseased  portion  of  the  joint  the 
tip  of  the  olecranon  process  was  united  by  a  strong  wire  suture 
to  the  sawn  surface  of  the  ulna.  The  wire  was  left  in  and 


414  TUBERCULOSIS   OF   THE   BONES    AND    JOINTS. 

patient   made  a  good  recovery,  and  the  functional  result  was 
satisfactory. 

Plachte  ("  Beitrag  zur  doppelseitigen  Ellbogen-resection." 
Dissertation.  Wiirzburg,  1885)  has  collected  twenty  cases  of 
double  resection  of  the  elbow-joint,  two  of  which  occurred  in 
the  klinik  in  Wiirzburg.  The  indications  were :  tubercular  dis- 
ease, thirteen  times ;  chronic  rheumatism,  four  times ;  inveterate 


FIG.  60. — BRACKETED  DOUBLE  SPLINT.    (Esmarch.) 

dislocations,  two  times ;  ankylosis  after  small-pox,  once.  Only 
one  of  the  cases  terminated  fatally.  In  most  cases  a  fair  mobil- 
ity, and,  in  some  of  them,  almost  normal  function  of  the  joint 
was  obtained.  Ankylosis  followed  on  one  side  in  two  of  the 


FIG.  61.— WOODEN  SPLINT  WITH  OPENING  FOR  INTERNAL  CONDYLE.    (Stromeyer.) 

cases.  In  eleven  cases  the  operations  were  made  from  one  to 
ten  years  apart.  At  the  same  time  in  three  cases,  and  in  six 
cases  no  reference  is  made  in  regard  to  the  time  of  the  operations. 
Fixation  of  the  olecranon  after  temporary  resection  of  this 
process  can  be  secured  by  two  durable  catgut  sutures.  I  have 
employed  thjs  method  of  fixation  in  a  number  of  cases,  and 
always  obtained  bony  union  and  an  excellent  functional  result. 


TUBERCULOSIS   OF   JOINTS   OF    UPPER    EXTREMITY. 


415 


The  arm  must  be  kept  supported  in  the  extended  position  by  a 
well-padded  anterior  splint,  or  in  a  plaster-of-Paris  case,  until 
bony  union  has  taken  place,  which  will  require,  according  to 
the  age  of  the  patient,  from  three  to  six  weeks. 

Figs.  60,  61,  62,  and  63  represent  some  of  the  splints  which 


FIG.  62.— CURVED  WOODEN  SPLINT. 

a,  upper  surface ;  b,  lateral  view ;  c,  wire  for  suspension. 

have  been  recommended  and  used  in  the  after-treatment  of  resec- 
tion of  the  elbow-joint. 

After  this  time  (three  to  six  weeks)  the  forearm  is  flexed 
gradually  from  day  to  day  until  it  can  be  flexed  at  right  angles 
with  the  arm.  Passive  and  active  motion  are  to  be  carefully 
but  persistently  practiced  after  this  time.  The  forearm,  after 
resection  of  the  elbow,  partial  and  complete,  manifests  a  strong 


416 


TUBERCULOSIS    OF    THE    BONES    AND    JOINTS. 


tendency  to  fall  in  a  position  of  pronation, — an  occurrence  which 
can  only  be  avoided  by  the  employment  of  carefully  prophylac- 
tic mechanical  measures  to  maintain  the  limb  in  a  desirable 
position. 


FIG.  63.— WIRE  SPLINT  INCASED  BY  PLASTER  OF-PAKIS  BANDAGE. 

Results. — The  functional  results  after  arthrectomy  and 
resection  of  the  elbow-joint  for  injury  or  disease  are  better  than 
after  similar  operations  upon  any  other  of  the  larger  joints. 
After  chisel  resection  of  the  joint  I  have  repeatedly  obtained 
almost  the  normal  range  of  flexion  and  extension  and  a  fair 
degree  of  rotation  of  the  forearm.  The  strength  and  utility  of 
the  resected  limb,  as  a  rule,  compares  favorably  with  the  oppo- 
site arm.  The  immediate  results  of  the  operation  are  not 
equally  satisfactory.  In  twelve  resections  of  the  elbow-joint 
made  by  Boeckel,  eleven  survived  the  operation  and  one  died, 
the  immediate  cause  of  death  being  acute  tuberculosis,  which 
developed  soon  after  the  operation.  Of  three  that  recovered 
from  the  operation  one  died  (child),  nine  months  later,  of  tuber- 
cular meningitis;  one  (adult),  after  a  year,  of  pulmonary  tuber- 
culosis, and  one  (child)  of  diffuse  miliary  tuberculosis.  Of  the 
eight  definitely  cured,  in  one  the  elbow  was  ankylosed  at  right 
angles,  and  in  another  the  same  condition  with  the  arm  in  a 
higher  degree  of  flexion  ;  the  remaining  five  (children  from  6  to 


TUBERCULOSIS   OF   JOINTS   OF   UPPER    EXTREMITY.  417 

13  years,  except  one)  recovered  perfect  use  of  the  arm.  Deaths 
from  pulmonary  tuberculosis  after  this  operation  will  be  less 
frequent  in  the  future,  when  surgeons  will  more  generally  recog- 
nize the  importance  of  early  operations,  and  will  be  more  careful 
in  removing  all  osseous  foci  and  infected  soft  tissues. 

Wrist- Joint. — The  wrist-joint  is  quite  frequently  the  seat 
of  tuberculosis.  In  this  joint  the  synovial  form  predominates. 
I  have  met  with  it  most  frequently  in  adults,  and  in  several 
cases  the  patients  were  from  50  to  60  years  of  age.  Tubercu- 
losis of  the  numerous  tendon-sheaths  surrounding  this  joint 
holds  often  a  direct  relationship  to  the  disease  within  the  joint, 
as  a  primary  tubercular  tendo-vaginalis  not  infrequently  invades 
the  joint,  and,  vice  versa,  primary  tuberculosis  of  the  joint  is 
very  prone  to  involve,  at  a  comparatively  early  stage,  the  ten- 
don-sheaths. From  a  diagnostic  point  little  is  to  be  said,  as  the 
external  appearances  of  a  tubercular  wrist-joint  are  so  charac- 
teristic and  typical  that  a  diagnosis  in  an  advanced  case  can  be 
made  almost  upon  first  sight.  In  advanced  cases  the  joint  is 
uniformly  swollen  and  the  hand  is  held  in  a  flexed  position. 
Marked  atrophy  of  the  muscles  of  the  forearm  is  a  conspicuous 
and  almost  constant  symptom.  Mono-articular  chronic  inflam- 
mation of  the  wrist-joint,  with  absence  of  any  acute  signs  or 
symptoms,  is  almost  safe  to  call  tubercular  in  its  origin,  course, 
and  consequences.  As  the  disease,  as  a  rule,  is  not  limited,  but 
involves  the  synovial  membrane  and  ligamentous  structures  of 
all  the  bones  which  enter  into  the  formation  of  this  joint,  the 
treatment  must  apply  to  all  of  these  structures.  Intra-articular 
and  parenchymatous  injections  of  iodoform  emulsion,  which 
have  yielded  very  satisfactory  results  in  tubercular  affections  of 
this  joint,  must  be  made  in  such  a  manner  as  to  bring  the  anti- 
bacillary  mixture  in  contact  with  every  portion  of  the  joint.  As 
the  carpal  bones  are,  almost  without  exception,  very  much 
softened,  they  can  be  penetrated  with  a  small  trocar  without 
difficulty,  and  by  doing  so  different  portions  of  the  joint  are 
reached  at  the  same  time,  and  the  injection  becomes  parenchy- 


418  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

matous  as  well  as  intra-articiilar.  The  joint  can  be  entered 
very  readily  on  the  nlnar  side  just  below  the  styloid  process, 
from  where  the  trocar  is  pushed  forward  until  its  point  reaches 
the  radial  side,  when  the  injection  is  made  at  intervals  as  the 
cannula  is  withdrawn.  In  repeating  the  operation  the  injection 
can  be  made  from  the  dorsal  side  at  different  points,  in  order  to 
reach  parts  inaccessible  to  the  transverse  puncture.  For  the 
purpose  of  preventing  flexion  of  the  hand  a  well-fitting  and 
carefully-padded  anterior  splint  should  be  applied,  reaching  from 
the  base  of  the  fingers  to  the  bend  of  the  elbow  with  the  hand 
in  a  slightly-extended  position.  lodoform  injections  should  be 
given  a  fair  trial  before  deciding  upon  excision  of  this  joint,  as, 
in  case  the  treatment  proves  successful,  the  functional  result  is 
much  more  satisfactory  than  after  operative  interference. 

RESECTION   OF   WRIST-JOINT. 

History  of  Operation. — The  first  resection  of  the  wrist- 
joint  was  made  by  Beyer  in  1762,  but  in  this  case  the  operation 
was  made  for  an  injury  caused  by  a  fragment  of  a  shell. 
Result  good.  In  1839  Dietz  made  the  first  resection  of  this 
joint  for  disease  (caries.)  The  disease  returned,  and  four  years 
later  the  forearm  was  amputated.  In  England  the  opera- 
tion was  performed  by  Fergusson  in  1851,  and  the  following 
year  Maisonneuve  reported  the  first  case  from  France.  Simon 
performed  the  operation  during  the  same  year,  Erichsen  in  1853, 
Butcher  in  1855,  Farn  in  1856,  Scymanowsky  in  1857,  and 
Bickersteth  in  1859. 

Incision. — Maisonneuve  resorted  to  a  straight  dorsal  in- 
cision. Chassaignac  made  a  similar  incision  on  the  ulnar  side 
of  the  joint. 

Doublet  advised  two  straight  incisions, — one  on  the  ulnar 
and  the  other  on  the  radial  side  of  the  joint.  The  same  method 
has  more  recently  been  advocated  by  Adelmann  and  Sprengler. 
Simon  preferred  two  straight  incisions, — one  over  the  dorsal, 
the  other  over  the  palmar  aspect  of  the  joint.  Roux  modified 


TUBERCULOSIS   OF    JOINTS   OF    UPPER    EXTREMITY. 


419 


Doublet's  method  by  adding  two  small  transverse  incisions  at 
the  lower  end  of  the  straight  cuts,  so  that  the  incisions  repre- 
sented two  Ls  with  the  transverse  bars  directed  toward  the 
dorsum.  Two  quadrangular  flaps,  formed  by  extending  the 
two  transverse  incisions  of  Roux,  represent  the  operation  as 


FIG.  64.— LANGENBECK'S  INCISION. 

a,  extensor  carpi  radialis  longior;  b,  extensor  longus  pollicig  :  c,  extensor  carpi  radialisbrevior;  d,  posterior  annular 

ligament. 

practiced  by  Diirr  and  Erichsen.  Fergusson's  method  consists 
in  uniting  the  two  incisions  of  Doublet  by  a  transverse  cut  about 
an  inch  above  the  joint. 

Velpeau  made  a  quadrangular  flap  with  the  base  directed 
toward  the  hand. 


420 


TUBERCULOSIS   OF    THE    BONES    AND    JOINTS. 


Guepratte  and  Butcher  recommended  a  semilunar  dorsal 
flap  with  base  directed  upward.  In  all  these  flap  operations  the 
incision  was  carried  only  down  to,  hut  not  through,  the  extensor 
tendons,  which,  during  the  further  steps  of  the  operation,  were 
to  be  kept  out  of  the  way  by  retractors. 

The  incisions  that  are  now  usually  practiced  in  resection  of 
the  wrist-joint  are  Lister's  double  dorsal  and  Langenbeck's  dorso- 
radial,  of  which  the  latter  is  preferred  by  Konig,  who  strongly 

recommends  it. 

Clinical  Studies.— Oilier  ("  Del 
a  resection  radio -carpienne." 
Bull  de  la  Soc.  de  Cliir.,  T.  ix) 
makes  his  incisions  according  to 
the  primary  starting-point  of  the 
disease.  If  the  disease  com- 
menced in  the  radius  and  ex- 
tended later  to  the  carpal  bones, 
he  removes  the  diseased  bones 
through  two  lateral  incisions  ;  on 
the  other  hand,  if  the  carpus  was 
primarily  affected  he  makes  one 
dorsal  incision  and  exercises  great 
care  not  to  injure  any  of  the 
tendons  of  the  extensor  muscles. 
He  reports  twenty-four  cases  of 
excision  of  the  wrist-joint,  in  twenty-two  of  which  the  operation 
was  made  for  caries  of  the  joint.  Three  of  the  patients  died,— 
one  of  sepsis  and  two  of  pyaemia.  He  believes  it  is  necessary 
to  keep  the  patient  under  observation  for  at  least  six  months, 
in  order  to  carry  out  the  necessary  after-treatment,  for  the  pur- 
pose of  securing  a  satisfactory  functional  result.  In  many  of 
his  cases  the  functional  results  were  highly  satisfactory.  Bidder, 
Heuter,  and  Langenbeck  favored  early  resection  for  tubercular 
affections  of  the  wrist-joint. 

Fahrenbach    (Deutsche  Zeitschrift  /.    Chirwgie,   B.    xxv 


FIG.  65.— LISTER'S  DOUBLK  INCISION. 


TUBERCULOSIS   OF   JOINTS   OF   UPPER   EXTREMITY.  421 

Heft  1  and  2)  reports  twenty-eight  cases  from  the  clinic  in  Goet- 
tingen,  in  which  resection  of  the  wrist  was  performed  for  tuber- 
cular disease,  and  proceeds  to  analyze  them  with  a  view  to 
determining-  the  value  of  the  operation  in  its  final  curative  effect, 
and  in  order  more  accurately  to  recognize  the  indication  for 
resection  of  this  joint.  Konig's  method  of  resection  for  this 
joint  is  based  upon  the  observation  that  the  carpus  is  generally 
primarily  attacked.  Langenbeck's  dorsal  incision  on  the  radial 
side  is  made,  after  application  of  Esmarch's  bandage,  and  the 
joint  opened  on  the  radial  side  of  the  extensor  tendon  of  the 
index  finger.  After  drawing  aside  the  tendons  with  retractors, 
the  carpal  bones  are  removed  by  means  of  a  large  Volkmaim 
spoon.  Finally,  all  diseased  soft  tissues  and  portions  of  approx- 
imate bones,  if  affected,  are  removed,  and  the  cavity  irrigated, 
iodoformized,  drained,  and  antiseptically  dressed.  The  hand  is 
maintained  in  a  position  of  dorsal  flexion,  at  first  by  the  fixa- 
tion dressing,  afterward  by  a  suitable  apparatus  of  steel  and 
leather.  Passive  movements  of  the  fingers  are  continued  from 
the  third  to  the  sixth  week.  In  twenty-two  cases  the  whole 
carpus  was  removed  in  the  manner  above  described,  although 
the  bones  were  not  all  affected.  No  deaths  occurred  from  the 
operation  ;  recovery  took  place  within  a  period  varying  from  one 
month  to  a  year.  In  five  cases  it  was  impossible  to  obtain  in- 
formation subsequently  to  their  discharge  from  the  hospital.  In 
sixteen  cases  a  small  fistula  remained, — not,  however,  interfering 
with  the  use  of  the  hand.  Two  of  the  patients  died  two  and 
six  months  respectively  after  operation,  in  consequence  of  other 
tubercular  affections.  Secondary  amputations  were  not  neces- 
sary, but  smaller  operations,  such  as  curetting  the  fistulae,  etc., 
were  resorted  to  in  six  cases  before  the  wound  finally  healed. 
The  functional  result  was  not  perfect  in  any  of  the  cases.  In  two 
cases  the  use  of  the  hand  was  nearly  normal.  In  eleven  cases 
the  patient  could  use  his  hand  to  work  in  the  field  and  perform 
other  diverse  manual  manipulations.  In  three  cases  the  impair- 
ment of  function  was  less  satisfactory,  and  in  three  additional 


4:22  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

cases  the  hand  could  only  be  used  for  holding  things.  Contrary 
to  Bidder  and  Schede,  Konig  insists  on  the  importance  of  remov- 
ing, in  every  case,  the  entire  carpus,  whether  all  the  bones  are 
diseased  or  not.  According  to  his  experience,  it  is  only  by  follow- 
ing this  advice  that  satisfactory  results  can  be  obtained.  It  is 
also  equally  important  to  maintain  the  hand  in  dorsal  flexion 
during  the  whole  time  of  healing  and  for  some  time  subseqently 
by  means  of  suitable  mechanical  contrivances. 

Resection. — Hoffman  (Deutsche  Med.  Wochenschrift,Decem- 
ber  25,  1890),  in  a  case  of  extensive  disease  of  the  wrist-joint, 
connected  Langenbeck's  radial  and  Lister's  ulnar  incision  by 
a  third,  transverse  cut,  corresponding  to  the  articulation  between 
the  two  rows  of  metacarpal  bones.  The  two  flaps  were  dissected 
upward  and  downward  separately,  and  the  whole  diseased  focus 
removed  en  masse,  including  the  carpal  end  of  the  metacarpal 
bones  .and  the  distal  extremities  of  the  radius  and  ulna.  The 
diseased  portions  of  the  extensor  tendons  of  the  hand  and 
fingers,  with  their  sheaths,  were  also  removed.  The  resected 
surfaces  were  brought  together  by  periosteal  catgut  sutures,  and 
the  ends  of  the  carpal  extensors  sutured  to  the  metacarpal 
periosteum  and  to  the  tendons  of  the  extensors  of  the  fingers. 
The  wound  healed  by  primary  union,  and  the  functional  result 
was  satisfactory  and  gradually  improving.  For  good  reasons, 
Konig  insists  that,  after  resection  of  the  wrist-joint,  the  hand 
should  be  dressed  in  a  position  of  one-third  dorsal  flexion  until 
the  new  joint  is  firm  enough  to  furnish  the  necessary  support, 
as  otherwise  displacement  of  the  resected  ends  is  very  liable  to 
occur.  He  maintains  this  position  for  six  months  by  means  of 
a  simple  dorsal  splint,  from  which  the  fingers  are  excluded. 
The  results  of  resection  of  the  wrist-joint  were  quite  satisfactory 
even  before  antiseptic  surgery  came  into  use.  Of  seventeen 
cases  reported  by  Gurlt  in  1865  only  three  died,  and  of  these 
three  deaths  two  were  caused  by  tuberculosis.  Of  fifteen  cases 
Lister  lost  only  two,  and  in  these  the  cause  of  death  had  no 
connection  whatever  with  the  operation.  The  functional  result 


TUBERCULOSIS   OF   JOINTS   OF    UPPER   EXTREMITY.  423 

has  seldom  proved  satisfactory.  Only  in  two-thirds  of  the  cases 
did  the  hand  become  useful.  In  tuberculosis  of  the  wrist-joint 
hi  which  the  iodoform  injections  have  been  thoroughly  tried 
and  have  been  found  inefficient,  resection  of  the  entire  wrist 
with  the  articular  surfaces  of  the  radius  and  ulna  and  the  heads 
of  the  metacarpal  bones  should  be  done,  as  partial  resection  is 
very  liable  to  be  followed  by  local  recurrence.  The  functional 
result  in  many  of  these  cases  is  excellent,  even  in  persons  some- 
what advanced  in  years. 

A  man,  44  years  of  age,  the  subject  of  typical  tubercu- 
losis of  the  wrist-joint,  came  under  my  care  at  the  Milwaukee 
Hospital.  The  clinical  history  did  not  reveal  any  hereditary 
tendency  to  tuberculosis  in  his  family,  and  he  was  otherwise 
in  excellent  health.  Patient  can  remember  from  boyhood  the 
existence  of  a  swelling  in  the  palm,  which,  on  flexion  of  the 
hand  and  fingers,  would  slip  up  under  the  annular  ligament. 
The  exact  time  when  the  present  joint  affection  commenced 
he  cannot  recall ;  for  the  last  two  years,  however,  the  joint 
has  been  swollen,  and  he  was  unable  to  use  the  hand  to  any 
extent.  The  bone  is  now  slightly  flexed  and  fingers  con- 
tracted; the  whole  joint  uniformly  swollen  and  cedematous. 
Extension  increases  the  pain.  Operation,  January  6,  1890: 
Straight  dorsal  incision.  Tendons  were  carefully  separated  over 
the  centre  of  the  joint,  and  kept  out  of  the  way  by  blunt 
retractors.  All  of  the  carpal  bones  and  articular  extremities  of 
radius  and  ulna,  as  well  as  every  vestige  of  the  infected  soft 
structures  of  the  joint,  were  removed.  After  iodoformization  of 
the  wound-surface  the  wound  was  sutured  and  dressed  anti- 
septically,  and  the  forearm  and  hand  immobilized  in  a  plaster- 
of-Paris  splint.  Wound  completely  healed  in  seventeen  days. 
Hand  kept  in  extended  position  for  six  weeks  longer,  after 
which  patient  had  good  use  of  hand,  and  function  improved 
steadily  for  nearly  a  year,  when  he  could  do  the  ordinary  work 
of  a  farmer. 

Spina    Ventosa.— The   term   spina  ventosa  has  been  em- 


424  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

ployed  for  a  long  time  to  designate  a  spindle-shaped  enlarge- 
ment of  the  long  bones  of  the  hand  and  foot,  which  the  old 
authors  almost  uniformly  regarded  as  one  of  the  manifestations 
of  scrofula.  As  the  term  is  still  being  used  largely  and  has  no 
reference  to  the  etiology,  the  modern  definition  of  the  affection 
should  be  "  tubercular  osteomyelitis  of  the  long  bones  of  the 
hand  and  foot." 

Bottchers  ("  Abhandlung  von  den  Krankheiten  der  Knoch- 
en,  Knorpel,  und  Sehnen,"  B.  cxi,  p.  121.  Konigsberg,  1792) 
gives  the  following  strange  definition  of  it :  "Den  Winddorn, 
spina  ventosa,  auch  cancer  ossis,  Teredo,  Wurm  im  Knochen, 
gangraena  ossis  genannt,  nennet  man  diejenige  Caries,  die  im 
Inneren  des  Knochens  anf  angt,  von  hier  nach  aussen  gehet,  und 
wobey  heftige  Schmerzen,  Aufblahung  des  Knochens  und  ein 
Ausfluss  einer  stinkenden  Gauche  ist." 

He  believes  that  this  affection  sometimes  follows  small-pox, 
and  alludes  to  syphilis  as  a  possible  cause,  but  regards  it  in 
most  cases  as  a  scrofulous  affection  of  bone.  He  is  conserva- 
tive in  his  treatment,  giving  preference  to  opening  of  the 
diseased  bone  and  removal  of  the  inflammatory  product  to 
amputation. 

Benj.  Bell,  in  his  classical  treatise  ("On  Diseases  of  the 
Bones,"  1828,  p.  128),  gives  an  excellent  description  of  the 
macroscopical  appearances  of  central  tubercular  osteomyelitis  of 
the  bones  of  the  hand  and  foot :  "  On  cutting  into  the  swelled 
bone  the  shell  of  the  tumor  appears  remarkably  attenuated,  and 
is  in  some  places  no  thicker  than  common  writing-paper,  and 
part  of  the  osseous  parietes,  indeed,  is  often  absorbed.  From 
the  internal  surface,  which  is  lined  by  a  delicate  membrane, 
small  spiculse  and  plates  of  bone  sometimes  project.  The  con- 
tents of  the  tumor  consist  of  a  sere-purulent  matter,  combined 
with  a  substance  not  unlike  gelatin  in  appearance."  In  spina 
ventosa  the  disease  commences  in  the  medulla  of  the  bones,  and 
is  very  correctly  described  as  a  tubercular  osteomyelits.  If  the 
process  is  rapid  sequestration  may  take  place,  the  dead  bone 


TUBERCULOSIS   OF   JOINTS   OF   UPPER   EXTREMITY.  425 

showing  varying  degrees  of  density,  according  to  the  extent  with 
which  it  was  affected  by  the  disease.  More  frequently  the 
process  is  slow,  and  the  inflammation  results  in  the  formation 
of  an  extensive  soft  mass  in  the  interior  of  the  bone,  which, 
however,  as  a  rule,  is  more  diffuse  than  is  the  case  in  the 
epiphysial  extremities  of  the  larger  long  bones.  The  enlarge- 
ment of  the  bone,  which  often  takes  place  to  an  enormous 
extent,  is  due  to  the  expansion  of  the  bone  by  the  accumulating 
product  of  tubercular  inflammation  within  and  by  new  formation 
of  bone  externally  from  the  periosteum. 

Renken  ("  Die  Osteomyelitis  der  Kleinen  Rohrenknochen 
an  den  Handen  u.  Fiissen  scrophuloser  Kinder  in  ihrer  Bezieh- 
ung  zur  Tuberculose."  JaJtrb.  f.  Kiiiderheilltunde,  B.  xxv, 
S.  215)  examined  the  inflammatory  product  in  the  granulation 
tissue,  removed  by  scraping,  in  five  children  suffering  from 
spina  ventosa,  and  found  tubercle  bacilli  in  all  of  them.  Spina 
ventosa  is  a  disease  of  infancy  and  childhood.  Goetz  ("  Etude 
sur  la  spina  ventosa."  Thdse,  Paris,  1877)  has  tabulated  thirty- 
five  cases  of  spina  ventosa,  with  a  view  to  ascertain  the  age  of 
patients  suffering  from  this  form  of  tuberculosis,  with  the 
following  result : — 

1  to    4  years, 23 

4  to    8  years,      . 7 

8  to  15  years,      .        .  ....        .        .        .      5 

He  is  of  the  opinion  that  the  disease  only  affects  the  shaft 
of  the  long  bones  of  the  hand  and  of  the  foot,  and  always  com- 
mences in  the  medulla,  the  bone  becoming  affected  secondarily. 

linger  ("  Zur  Pathologic  und  Therapie  der  Spina  ventosa." 
Arch.  f.  Kinderheilknnde,  1889,  Heft  xi)  has  collected,  during 
the  last  six  years,  the  clinical  histories  of  eighty  patients  that  were 
treated,  in  the  Jewish  Hospital  in  Berlin,  for  spina  ventosa,  or 
ostitis  tuberculosa  of  the  shaft  of  long  bones,  as  he  calls  it. 
Of  this  number  forty-five  had  not  reached  the  age  of  5  years, 
the  remaining  patients  were  older,  and  five  had  passed  the 
tenth  year.  The  oldest  patient  was  15.  The  metacarpal  bones 


426  TUBERCULOSIS   OF   THE    BONES   AND   JOINTS. 

were  most  frequently  the  seat  of  the  disease,  namely,  40  times ; 
then  followed  the  phalanges  of  the  ringers,  38  times ;  the  meta- 
tarsal  bones,  13  times ;  the  phalanges  of  the  toes,  3  times ;  ulna 
and  tibia,  each,  3  times ;  radius  and  inferior  maxilla,  each,  2 
times.  The  observations  made  in  connection  with  these  cases 
showed  plainly  enough  that,  in  order  to  obtain  a  good  functional 
and  cosmetic  result,  it  is  necessary  to  operate  early. 

Treatment. — In  order  to  show  what  progress  has  been 
made  in  the  surgical  treatment  of  tuberculosis  of  bone  during 
the  last  fifty  years,  I  will  quote  Benj.  Bell  on  the  treatment  of 
spina  ventosa :  "  The  treatment  of  spina  ventosa  is  very  simple, 
as  the  surgeon,  when  he  is  assured  of  its  existence,  must  at 
once  have  recourse  to  the  amputating  knife.  If  the  disease  is 
seated  in  the  bones  of  the  metacarpus  or  metatarsus,  as  is  gen- 
erally the  case  in  childhood,  they  should  be  removed  at  their 
articulations.  If  it  has  attacked  the  tibia  and  fibula,  or  radius 
and  ulna,  the  amputation  may  be  performed  either  at  the  knee 
or  elbow  or  a  short  way  above  these  joints.  The  general  rule 
to  be  observed  is  that  the  entire  bone  in  which  the  disease  has 
its  seat  should  be  removed."  Spina  ventosa  presents  the  most 
favorable  conditions  for  successful  treatment  by  means  of  paren- 
chymatous  injections  of  iodoform  emulsion  or  other  antibacillary 
agents.  The  compact  layer  of  the  bone  has  become  so  much 
expanded  by  the  increased  mtra-osseous  tension  and  has  been 
rendered,  at  the  same  time,  so  osteoporotic  that  it  can  be  easily 
penetrated  with  the  needle  of  an  ordinary  hypodermatic  syringe, 
which  is  also  used  for  injecting  the  emulsion  or  solution.  When 
the  procedure  is  repeated  the  puncture  should  be  made  in  a 
different  direction,  so  that  gradually  the  whole  intra-osseous 
focus  is  saturated  with  the  antibacillary  remedy.  If  the  affec- 
tion does  not  yield  to  this  method  of  treatment,  or  if  fistulous 
communications  already  exist,  the  bone  should  be  exposed  at  a 
point  where  it  is  most  superficial  and  where  important  struc- 
tures, such  as  tendons,  large  vessels,  and  nerves  can  be  avoided, 
and,  after  incising  and  reflecting  the  periosteum,  the  whole 


TUBERCULOSIS   OF   JOINTS   OF    UPPER   EXTREMITY.  427 

length  of  the  focus  is  exposed  by  removing  the  external  com- 
pact layer  with  a  small  chisel,  when  the  tubercular  product  is 
carefully  scraped  out  with  a  sharp  spoon  and  the  resulting 
cavity  treated  in  the  same  manner  as  in  operations  for  similar 
lesions  on  large  bones,  —  iodoformization  and  packing  with 
decalcified  antiseptic  bone-chips,  —  after  which  the  periosteum 
is  stitched  over  the  packing  and  the  external  wound  closed  in 
the  usual  manner.  Amputation  can  only  come  up  for  consid- 
eration if  this  operation  prove  a  failure,  or  when  one  of  the 
adjacent  joints  has  become  invaded. 


CHAPTER  XXXV.     . 

TUBERCULOSIS  OF  HIP-JOINT. 

MORBUS  coxarius,  coxitis,  and  hip  disease  are  terms  used 
to  designate  a  tubercular  inflammation  of  the  hip-joint.  The 
causation  and  nature  of  chronic  inflammatory  affections  of  this 
joint  have  been  the'  subjects  of  a  great  deal  of  discussion  and 
dissent  for  many  years.  The  old  authors  regarded  it  as  one  of 
the  local  conditions  caused  by  a  scrofulous  dyscrasia ;  more 
recently  many  have  traced  its  etiology  exclusively  to  trauma ; 
but  at  the  present  time  its  tubercular  nature  is  questioned  by 
only  a  few. 

Age. — Tubercular  inflammation  of  the  hip-joint  is  found 
more  frequently  in  children  than  adults.  Bryant  ("  On  Hip 
Disease."  Medical  Times  and  Gazette,  July  3  to  October  16, 
1 869)  observed  three  hundred  and  fifty  cases  of  hip  disease,  and 
of  this  number  62  per  cent,  occurred  in  children  less  than  10 
years  of  age  and  80  per  cent,  before  the  twentieth  year. 

Primary  Location  of  Disease. — In  this,  as  in  all  diarthrodial 
joints,  the  disease  may  begin  in  the  synovial  membrane  or  in 
the  bone ;  but,  on  account  of  the  deep  location  of  the  joint,  it 
is  not  easy,  during  life,  to  determine  the  relative  frequency  of 
each.  Konig  examined  15  museum  specimens,  and  found  that 
the  disease  had  a  primary  osseous  origin  in  8,  and  synovial  in 
7.  Haberern  ("  Ueber  Beckenabscesse  bei  Coxitis  und  ihre 
Behandlung."  Centralblatt  f.  Chirurgie,  No.  1314,  1881)  has 
found,  in  studying  132  cases  of  resection  of  the  hip-joint,  with 
special  reference  to  the  location  of  osseous  foci,  that  in  50  cases 
caseous  foci  were  present  in  the  acetabulum  31  times  with  and 
19  times  without  sequestra;  in  23  the  foci  were  located  in  the 
head  or  great  trochanter  of  the  femur  14  times  with  and  9  times 
without  necrosis.  In  29  cases  carious  defects  in  the  acetabulum 
and  neck  of  femur  were  so  extensive  that  the  exact  location  of 
the  primary  disease  could  not  be  ascertained.  In  23  cases  the 
(428) 


TUBERCULOSIS   OF    HIP-JOINT.  429 

disease  was  probably  of  a  primary  synovial  origin.  Of  12 
cases  examined  by  Watson  Cheyne  (British  Medical  Journal, 
April  4,  1891),  section  showed  primary  osseous  lesions  in  5;  in 
the  rest  it  was  somewhat  doubtful  as  to  whether  the  disease 
commenced  in  the  synovial  membrane,  as  he  had  not  the  oppor- 
tunity to  examine  the  acetabulum  in  all  instances.  He  is,  how- 
ever, of  the  opinion  that  a  primary  osseous  origin  is  more  fre- 
quent in  this  than  the  knee-joint.  Most  authors  agree  that  it 
commences  more  frequently  in  the  acetabulum  than  the  femur. 
In  Haberern's  80  cases  of  primary  bone  disease  in  this  locality 
the  acetabulum  alone  was  the  seat  in  50,  the  femur  alone  in 
23,  and  both  bones  together  in  7.  In  the  femur  the  starting- 
point  is  most  frequently  in  the  neck,  on  the  distal  side  of  the 
epiphysial  cartilage,  the  epiphysis  itself  being  usually  exempt.  In 
the  acetabulum  it  attacks  the  vicinity  of  the  V-shaped  cartilage. 
In  the  majority  of  cases  the  disease  terminates  in  sequestration, 
caseous  foci,  without  necrosed  bone  being  comparatively  rare. 

In  Haberern's  50  cases  of  primary  acetabular  disease,  in 
31  sequestra  were  present,  in  19  no  necrosis,  while  in  the  femur 
sequestra  were  present  in  14  and  absent  in  9,  and  in  the  7  cases 
where  both  bones  were  affected  necrosed  bone  was  found  in  6 
and  absent  only  in  1.  A  primary  focus  in  the  neck  of  the  femur 
grows  in  the  direction  of  the  epiphysial  cartilage  and  toward  the 
surface  of  the  bone.  When  the  disease  reaches  the  synovial 
membrane  the  whole  of  the  interior  of  the  joint  becomes  rapidly 
involved.  At  the  point  of  reflection  of  the  synovial  membrane 
it  reaches  the  articular  cartilage,  which  is  affected  from  the  sides 
and  at  the  point  of  insertion  of  the  round  ligament  almost  simul- 
taneously. The  epiphysial  cartilage  is  destroyed  at  the  same 
time,  resulting  often  in  complete  epiphysiolysis.  If  the  primary 
focus  is  located  near  the  trochanter  major  the  disease  may  not 
extend  into  the  joint,  but  remain  extra-articular,  and  eventually 
the  synovial  membrane  is  apt  to  become  involved  during  the 
progress  of  the  disease.  The  extensive  destruction  of  the  bony 
constituents  of  the  joint  is  brought  about  by  extension  of  the 


430  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

tubercular  process  and  the  rarefying  osteomyelitis  which  attends 
it.  The  pressure  between  the  articular  surfaces,  caused  by 
reflex  muscular  contractions,  is  an  important  element  in  the 
speedy  and  extensive  destruction  of  bone  in  tubercular  disease 
of  this  joint.  The  acetabulum  enlarges  in  an  upward  direction 
under  the  pressure  exerted  by  the  head  of  the  femur,  giving  rise 
to  shortening  of  the  limb.  True  dislocation  may  be  caused,  in 
such  cases,  by  the  slightest  application  of  force,  under  such  cir- 
cumstances, and  sometimes  this  accident  occurs  when  the  articu- 
lar surfaces  have  not  been  much  affected,  if  the  soft  structures 
of  the  joint  have  undergone  extensive  disease.  A  partial  dis- 
location is  quite  common  in  connection  with  destruction  of 
the  rim  of  the  acetabulum.  Complete  dislocation  is  often  pre- 
vented by  the  formation  of  a  buttress  of  new  bone  by  plastic 
periostitis. 

Symptoms. — Only  a  few  of  the  more  conspicuous  symptoms 
of  coxitis  will  be  discussed  here.  The  sympathetic  pain  in  the 
knee-joint  which  is  so  often  associated  with  the  osseous  form  of 
hip  disease  has,  up  to  date,  not  been  satisfactorily  explained. 
Various  theories  have  been  advanced,  but  none  of  them  fully 
explain  this  phenomenon. 

Sir  Charles  Bell  believed  that  the  pain  is  communicated  by 
means  of  the  obturator  nerve.  "  The  obturator  nerve,"  he  says, 
"  passes  through  the  thyroid  foramen  down  to  the  hip-joint, 
and,  after  supplying  the  muscles,  is  distributed  upon  the  inner 
part  of  the  knee.  The  nerve,  in  its  course,  is  thus  involved  in 
the  inflammation  which  affects  the  hip-joint,  and  the  pain  is 
referred  to  its  extensive  cutaneous  branches  at  a  part  distant 
from  the  seat  of  the  disease." 

Coulson  ("On  Diseases  of  the  Hip-Joint,"  etc.  London, 
1841)  maintains  that  the  pain  in  the  knee  commences  with  the 
extension  of  the  disease  to  the  capsule  of  the  joint.  As.  the 
pain  sometimes  extends  to  the  middle  and  outer  part  of  the 
thigh,  in  localities  out  of  reach  of  the  obturator  nerve,  he  ex- 
plains this  symptom  by  the  intimate  connection  which  exists 


TUBERCULOSIS    OF    HIP-JOINT 


431 


between  the  long  head  of  the  rectus  femoris  muscle  with  the 
outer  edge  of  the  acetabulum  and  with  the  capsular  ligament, 
believing  that  the  fascia  of  this  muscle  may  take  on  the  inflam- 
matory action,  and  the  pain  in  this  way  be  conveyed  down  the 
limb  to  the  thigh.  He  argues  that  we  have  an  analogy  to  this 
in  disease  of  the  shoulder-joint,  the  pain  in  these  cases  often 

extending  down  the  front  of  the  arm 
to  the  insertion  of  the  biceps.  The 
different  faulty  positions  of  the  limb, 
from  slight  flexion  and  rotation  out- 


Fio.  66.— COXITIS,  LEFT  SIDE. 

Slight  abduction  and  rotation  of  limb  outward  and 
apparent  elongation  of  limb.  Gluteal  crease  diminished 
and  lower  down,  nates  flattened. 


FIG.  67.— COXITIS,  LKFT  SIDE,  SECOND 
.STAGE. 

Limb  shortened,  addncted,  and  rotated  inward,  nates 
preternaturally  pre-eminent  and  elevated.  Ghiteal  crease 
higher  than  on  opposite  side. 


ward,  characteristic  of  the  first  stage  to  the  most  aggravated 
deformity  attending  or  simulating  complete  dislocation,  have 
also  been  extensively  discussed  and  variously  interpreted. 

F.  Busch  ("Ueber  Coxitis."  Deutsche  Ned.  Wochenschrift, 
No.  14,.  1 878)  claims  that  the  primary  abduction  and  rotation 
outward  in  coxitis  are  caused  by  tension  of  the  ilio -femoral 


432 


TUBERCULOSIS    OF    THE    BONES    AND   JOINTS. 


ligament,  as  the  intra-capsular  inflammatory  product  crowds 
the  head  of  the  femur  away  from  the  acetabulum.  If,  later,  the 
acetabulum  is  dilated  by  pressure  of  the  head  of  the  femur,  the 
head  slips  backward  and  the  tension  of  the  same  ligament  then 
rotates  the  limb  inward.  In  opposition  to  this  explanation 
Kolaczeck  ("  Die  ^Etiologie  der  mechanischen  Symptome  bei 
der  Huftgelenkentziindung  der  Kinder."  Deutsche  Med.  Wock- 

enscliri/t,  Nos.  31-32,  1878)  supports  the 
accommodation  theory  to  explain  the 
position  of  the  limb  in  coxitis.  In  the 
first  stage  the  limb  is  abducted  in  order 
to  bring  the  pressure-point  outward,  thus 


FIG.  68.— TIIIBD  STAGE  OF  COXITIS. 


The  characteristic  deformity  of  second  stage 
greatly  aggravated. 


FIG.  69.— THIRD  ST^GK  OF  COXITIS. 

Limb  greatly  shortened  and  rotated  outward. 


taking  off  the  pressure  from  the  extremity.  Rotation  outward 
takes  place  to  prevent  pes  varus  position  of  the  foot.  Flexion 
of  the  thigh  upon  the  pelvis  has  for  its  object  to  bring  the 
pressure-point  nearer  the  anterior  portion  of  the  upper  rim  of  the 
acetabulum,  which  also  aids  in  the  diminution  of  pressure,  while 
the  limb  is  placed  in  a  semi-flexed  position.  In  the  later  stages 
of  the  disease  flexion  is  maintained  bv  the  contracted  fascia. 


TUBERCULOSIS   OF   HIP-JOINT. 


433 


The  second  stage  indicates  the  existence  of  beginning  de- 
struction of  the  bony  constituents  of  the  joint  attended  by 
permanent  deformity.  The  third  stage  is  characterized  by  a 
position  of  the  limb  which  characterizes  partial  or  even  complete 
dislocation  of  the  hip  in  the  direction  of  the  dorsum  of  the  ilium. 
The  prolonged  muscular  contractions  and  traction  of  the  short- 
ened anterior  portion  of  the  capsular  ligament,  combined  with 
destruction  of  bone  by  the  tubercular  inflammation  and  pressure 
atrophy,  lead  to  this  result. 


Fio.  70. — POSITION  OF  LIMB  IN  DORSAL  KECUMBENT  POSITION  OF  PATIENT 
DURING  THE  EARLY  STAGE  OF  COXITIS. 

If  separation  of  the  head  (epiphysiolysis)  take  place,  or  if 
the  neck  of  the  bone  is  extensively  destroyed,  the  limb  may 
rotate  outward,  and  the  conditions  then  presented  resemble  a 
fracture  of  the  neck  of  the  femur. 


FIG.  71.— TILTING  OF  PELVIS  AND  CURVING  OF  SPINE  WHEN  AFFECTED 
LIMB  is  BROUGHT  DOWN  EVEN  WITH  THE  LIMB  ON  OPPOSITE  SIDE. 

One  of  the  earliest  and  most  significant  symptoms  of  coxitis 
is  an  inability  on  the  part  of  the  patient  to  extend  the  thigh  fully 
and  the  failure  on  the  part  of  the  surgeon  to  correct  the  flexion 
without  the  use  of  an  anaesthetic  to  the  extent  of  securing 
perfect  relaxation  of  the  muscles. 

Aggravation  of  pain  by  pressure  against  the  sole  of  the 
foot  when  limb  is  extended,  and  against  the  great  trochanter  in 
the  direction  of  the  neck  of  the  femur,  as  well  as  on  active  and 
passive  motion  of  the  joint,  is  an  important  and  early  symptom. 


28 


434  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

Atrophy  of  muscles  is  a  constant  and  well-marked  symptom  in 
tubercular  inflammation  of  this  as  well  as  any  other  joint. 

Prognosis. — The  prognosis  in  coxitis  is  greatly  modified  by 
the  age  of  the  patient,  the  stage  of  the  disease,  and  the  general 
condition  of  the  patient.  It  is  much  more  favorable  in  children 
than  adults.  Coxitis  which  has  advanced  to  the  formation  of 
abscesses  in  adults  necessarily  gives  rise  to  a  very  unfavorable 
prognosis,  and  the  prospects  of  a  favorable  termination  by  oper- 
ative treatment  under  these  circumstances  are  indeed  very  doubt- 
ful. The  co-existence  of  tuberculosis  in  other  joints  or  organs, 
or  amyloid  degeneration  of  important  internal  organs,  is  almost 
sure  to  lead  to  a  fatal  termination,  irrespective  of  the  primary 
joint-lesion.  Appropriate  early  local  and  general  treatment  is 
of  the  greatest  value  in  arresting  the  disease  before  irreparable 
destructive  changes  have  occurred,  and  in  preventing  reinfection 
of  the  body  from  the  affected  joint. 

Ford  ("Observations  on  the  Disease  of  the  Hip-Joint," 
etc.,  p.  9.  London,  1810)  expected  more  from  treatment  of 
hip-joint  disease  in  its  incipiency  than  most  of  his  contempo- 
raries. "As  far  as  my  experience  goes,  the  ill  success  attending 
the  treatment  of  these  cases  has  been  more  owing  to  a  want  of 
distinguishing  properly  the  nature  of  the  complaint  in  its  early 
period,  or  to  the  neglect  and  indifference  of  the  patients  them- 
selves, than  to  the  incurable  nature  of  the  malady,  or  to  a  defect 
of  power  in  the  healing  art." 

If  the  patient  is  young  and  the  general  condition  favorable, 
efficient  local  and  general  treatment  often  results  in  a  cure  with- 
out the  formation  of  abscesses,  with  a  somewhat  stiff  but  useful 
joint.  Very  often,  ultimately,  recovery  takes  place  after  the 
joint  has  suppurated  for  years,  resulting  in  extreme  emaciation 
of  the  patient ;  but  in  such  instances  bony  ankylosis,  with  the 
thigh  flexed  and  the  limb  shortened,  abducted  or  adducted,  is 
the  rule.  Such  an  event,  however,  is  only  possible  when  the 
tuberculosis  is  limited  to  the  joint  and  when  the  internal  organs 
remain  healthy. 


TUBERCULOSIS   OF   HIP-JOINT. 


435 


TREATMENT. 

Extension  and  Fixation. — Benj.  C.  Brodie  ("  Diseases  of 
the  Joints,"  p.  139.  London,  1850)  gave  extension  a  trial,  but 
the  means  employed  were  so  imperfect  that  the  method  could 
not  be  satisfactorily  carried  out.  "  In  some  cases  where,  the 
disease  being  in  an  advanced  stage,  there  seemed  reason  to 
apprehend  a  displacement  of  the  head  of  the  femur,  with  a 
retraction  of  the  limb,  I  have  endeavored  to  prevent  it  by  the 
application  of  a  moderate  but  constant  extending  force.  For 
this  purpose  a  leather  strap  was  applied  above  the  condyles  of 
the  femur,  having  a  string  attached  to  it,  passing  over  a  pulley, 


FIG.  72.— EXTENSION  BY  WEIGHT  AND  PULLEY. 

fixed,  at  a  moderate  height,  to  the  lower  end  of  the  bedstead, 
and  supporting  a  light  weight,  the  pelvis  being  at  the  same  time 
fixed  by  a  strap  to  the  middle  or  upper  end  of  the  bedstead. 
This,  in  some  instances,  seemed  to  relieve  pain,  and  I  am 
inclined  to  think  that  it  was  useful  otherwise,  by  counteracting 
the  muscles,  which  tended  to  draw  the  limb  upward.  However, 
it  almost  always  happened  that  something  occurred  to  prevent 
the  experiment  being  fully  and  fairly  tried ;  and  all  I  can  ven- 
ture to  say  respecting  it  is,  that  it  may  be  worth  while,  in  certain 
cases,  to  give  this  mode  of  treatment  a  further  trial."  The  value 
of  extension,  in  the  treatment  of  inflammation  of  the  hip-joint, 


436 


TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 


is  admitted  on  all  sides,  but  the  methods  of  carrying  it  out  vary. 
Extension  by  weight  and  pulley  with  the  patient  in  the  recumbent 
dorsal  position  is  the  most  efficient,  and  should  be  resorted  to  in 

all  cases  in  which  pain  /*  a 
prominent  symptom  and  where 
the  muscles  around  the  hip- 
joint  have  become  contracted. 
Extension  in  such  cases  usu- 
ally promptly  relieves  the  pain 
and  not  only  prevents  further 
contraction,  but  is  one  of  the 
best  means  to  correct  displace- 
ments. Extension  is  applied 
in  the  same  manner  as  in 


V 


FIG.  73.— THOMAS'  SPLINT  ARRANGED 
FOR  WALKING,  WITH  CRUTCHES  AND  PAT- 
TEN UNDER  FOOT  ON  SOUND  SIDE. 


FIG.  74.— DOUBLE  THOMAS'  SPLINT. 


fractures  of  femur, — by  strips  of  adhesive  plaster,  which  should 
extend  a  considerable  distance  beyond  the  knee-joint.  The 
weight  to  be  employed  must  be  adjusted  to  meet  the  indications 
of  each  individual  case, — from  two  to  fifteen  pounds,  according' 


TUBERCULOSIS   OF    HIP-JOINT. 


437 


to  age  of  the  patient  and  the  degree  of  contraction  and  sense 
of  relief.  A  good  rule  is,  to  rely  on  the  sensation  of  the  patient 
in  the  matter  of  weight,  commencing  with  a  light  weight  and 
increasing  it  gradually  until  pain  is  relieved,  when  it  can  be 
said  that  extension  has  been  carried  to  the  .point  of  comfort. 
Extension  by  the  different  kinds  of 
•iralkiuy  splints  cannot  be  relied 
upon  in  cases  in  which  this  method 


FIG.  75.— SAYRE'S  LONG  HIP-SPLINT. 


FIG.  7(i. — VOLKMANN'S  SPLINT  APPLIED. 


of  treatment  is  indicated.  Auto-extension,  as  advised  by 
Hutchinson,  is  an  exceedingly  valuable  aid  to  the  treatment 
during  the  early  stage  of  the  disease,  before  much  contraction 
has  taken  place;  also  as  a  means  of  continuing  this  principle  of 
treatment  after  extension  by  weight  and  pulley  has  been  discon- 
tinued, and  during  the  treatment  after  resection  of  the  hip-joint 


438  TUBERCULOSIS   OF    THE    BONES    AND   JOINTS. 

Fixation  of  an  inflamed  joint  is  one  of  the  most  important  ele- 
ments of  successful  treatment.  The  numerous  mechanical  de- 
vices which  have  been  invented  and  manufactured  for  making 
extension  have  proved  useful  not  on  account  of  the  traction 
which  they  were  supposed  to  effect,  but  as  a  means  of  procuring 
immobilization.  Of  the  different  walking  splints  invented  for 
the  purpose  of  making  extension,  those  of  Thomas,  Sayre,  and 
Volkmann  are  the  best. 

If  the  limb  is  in  normal  position,  or  has  been  brought  in 
this  position  by  extension,  fixation  of  the  joint  and  immobiliza- 
tion of  limb  can  be  secured  in  a  plaster-of- Paris  bandage  extend- 
ing from  the  toes  and  embracing  the  entire  limb  and  the  pelvis. 
With  such  a  dressing  the  patient  can  be  taken  out-doors  and 
can  walk  on  crutches,  as  during  walking  the  necessary  extension 
can  be  made  by  suspension  of  the  affected  limb  if  the  shoe  on 
the  opposite  side  is  supplied  with  a  raised  sole,  as  advised  by 
Hutchinson.  This  method  of  treatment  should  be  continued 
until  the  inflammation  in  the  joint  has  subsided, — a  condition 
which  can  be  determined  by  disappearance  of  pain  and  tender- 
ness and  subsidence  of  any  tendency  to  further  contraction  of 
the  flexor  muscles  of  the  thigh.  Intra-articular  and  parenchy- 
matous  injections  of  iodoform  should  be  tried  in  all  cases  of 
primary  and  secondary  tuberculosis  of  the  hip-joint  before  and 
after  the  formation  of  para-articular  abscesses,  before  resorting 
to  excision  of  the  joint. 

Extra-articular  Operations  in  Primary  Osseous  Tubercu- 
losis of  the  Hip-Joint. — Mr.  Symonds  (British  Medical  Journal, 
May  16,  1891)  has  recorded  two  cases  in  which  he  removed  a 
tubercular  sequestrum  from  the  neck  of  the  femur  without 
injury  to  the  joint;  the  patients  were  aged,  respectively,  3  and 
5  years.  In  both  there  was  a  large  chronic  abscess  on  the  front 
and  outer  aspect  of  the  thigh,  without  any  pain  in  the  joint. 
Both  children  were  able  to  walk  with  only  a  slight  limp.  The 
movements  of  the  joints  in  each  case  were  only  slightly  impaired. 
In  the  first  case  the  presence  and  situation  of  the  sequestrum 


TUBERCULOSIS    OF    HIP-JOINT.  439 

were  suspected;  in  the  second  it  was  searched  for  after  the 
abscess  was  opened.  In  both  a  minute  sinus  was  found  leading 
th rough  the  front  of  the  neck  into  a  cavity.  The  channel  was 
enlarged  by  gouging  away  a  little  bone  from  the  outer  side  and 
the  sequestrum  removed.  In  both  the  capsule  was  seen  lifted 
up  by  the  abscess  ;  in  the  first  it  was  accidentally  opened  by  a 
slip  of  the  knife ;  in  the  second  it  was  intentionally  pricked, 
and  in  botli  cases  a  few  drops  of  clear  fluid  escaped.  Both 
sequestra  involved  the  epiphysial  aspect  of  the  neck,  and  in  the 
first  case  the  piece  of  bone  was  of  considerable  size.  In  the 
first  ca.se,  operated  on  in  1887,  the  wound  was  stuffed  and 
drained.  In  the  second,  operated  on  in  May,  1889,  according 
to  the  method  introduced  by  Mr.  Barker,  the  large  abscess,  after 
being  scraped  out,  was  sewn  up,  and  this  was  followed  by 
primary  union.  At  the  time  the  report  was  made  the  elder 
patient,  a  boy  aged  7,  had  a  perfectly  useful  joint,  possessing 
all  the  normal  movements,  and,  moreover,  there  was  no  shorten- 
ing and  no  irregular  growth.  The  other,  the  first  operated  on, 
had  a  limb  of  normal  length,  but  the  joint  was  fixed.  At  the 
same  time  Watson  Cheyne  (ibid..,  p.  1073)  reported  three  cases 
of  tuberculosis  of  the  neck  of  the  femur  in  which  sequestra 
were  removed  from  the  usual  situation  below  and  just  outside 
the  epiphysial  line  without  any  suppuration  being  present.  The 
diagnosis  was  made  first  by  excluding  acetabular  disease  by 
rectal  examination,  next  by  thickening  about  the  trochanter  and 
neck  of  the  femur  implying  bone  disease,  and,  thirdly,  by 
thickening  of  the  capsule  implying  communication  with  the 
joint.  In  a  fourth  case  absence  of  thickening  of  the  capsule 
showed  that  the  disease  in  the  bone  did  not  communicate  with 
the  joint,  and,  therefore,  did  not  involve  the  surface  of  the  bone, 
and  consequently  an  incision  was  made  over  the  outer  side  of 
the  trochanter  and  a  channel  scooped  out  along  the  neck  of  the 
femur  till  a  caseous  mass  was  found  just  outside  the  epiphysjal 
cartilage.  The  case  made  an  excellent  recovery.  A  similar  case 
from  Volkmaun's  clinic  was  previously  alluded  to.  (Fig.  20.) 


440  TUBERCULOSIS   OF   THE   BONES   AND    JOINTS. 

The  frequency  with  which  coxitis  commences  on  the  ace- 
tabular  side  should  lead  surgeons  to  search  early  and  carefully 
for  osseous  foci  in  the  innominate  bone  near  the  acetabulum,  and, 
if  such  foci  can  be  located  with  a  sufficient  degree  of  accuracy, 
extra-articular  operations  would  not  only  be  indicated,  but  would 
prove  successful  both  as  curative  and  prophylactic  procedures. 
According  to  the  location  of  the  focus,  a  large  anterior  or 
posterior  incision  would  be  required  to  locate  and  remove  the 
diseased  tissue. 

Arthrectomy. — Schede  has  made  a  number  of  attempts  to 
substitute  the  more  conservative  operation  of  arthrectorny  for 
typical  resection  in  synovial  tuberculosis  of  the  hip-joint.  He 
makes  a  large,  posterior,  curved  incision,  divides  the  posterior 
portion  of  the  capsular  ligament,  and  dislocates  the  head  of  the 
femur  upon  the  dorsum  of  the  ilium  and  extirpates  the  synovial 
membrane  with  the  capsule  and  ligamentum  teres.  After  re- 
moval of  all  of  the  infected  tissues  and  thorough  iodoformization 
of  the  joint,  the  head  of  the  bone  is  reduced  and  the  wound 
treated  in  the  same  manner  as  after  resection.  Three  years  ago 
I  had  the  pleasure  of  being  present  at  one  of  these  operations 
while  visiting  his  clinic,  and  became  fully  convinced  of  the  many 
difficulties  which  surround  an  arthrectomy  of  this  joint.  Even 
if  the  results  should  warrant  such  an  operation,  its  scope  will 
always  remain  limited  on  account  of  the  frequency  with  which 
synovial  tuberculosis  of  this  joint  is  complicated  by  disease  of 
the  acetabulum,  head  or  neck  of  the  femur. 

Resection. — Benjamin  C.  Bell  ("  Diseases  of  Joints,"  p.  141. 
London,  1850)  regards  resection  of  the  hip-joint  appropriate 
only  in  cases  where  the  head  of  the  femur  is  found  dislocated 
on  the  dorsum  of  the  ilium  and  can  be  distinctly  felt  through 
the  attenuated  soft  parts,  and  even  in  such  cases  the  procedure 
does  not  meet  with  his  approval,  as  may  be  seen  from  the  follow- 
ing :  "  In  such  a  case  it  has  been  proposed  to  make  an  incision 
on  it  (the  head  of  the  femur)  and  remove  the  head  and  neck  of 
the  femur  by  a  saw,  It  would  appear  that  this  operation  has 


TUBERCULOSIS   OF    HIP- JOINT.  441 

been  Actually  performed  with  some  degree  of  advantage,  and  I 
do  not  doubt  that  circumstances  may  occur  to  make  it  worth 
while  to  have  recourse  to  it;  but  it  is  to  be  observed,  at  the 
same  time,  that  all  that  can  be  thus  accomplished  is  the  removal 
of  one  portion  of  the  disease,  and  that  it  is  the  largest  portion 
of  it,  in  the  bone  of  the  pelvis,  which  is  necessarily  allowed  to 
remain.  The  operation  cannot  be  performed  without  a  certain 
degree  of  local  disturbance  and  more  or  less  loss  of  blood,  and, 
taking  all  these  things  into  consideration,  I  conceive  that  we 
should  not  recommend  it  except  where  some  very  unequivocal 
advantage  may  be  expected  from  it." 

Since  the  time  this  was  written  a  radical  change  of  opinion 
in  reference  to  the  propriety  of  operative  interference  in  hip 
disease  has  taken  place.  The  operation  is  now  almost  univer- 
sally sanctioned  in  all  cases  where  mere  expectant  treatment, 
such  as  extension,  fixation,  and  parenchymatous  and  intra- 
articular  injections  have  failed  to  arrest  the  progress  of  the 
disease,  and  the  general  condition  of  the  patient  furnishes  no 
centra-indication. 

RESECTION    OF    HIP-JOINT. 

History. — Removal  of  the  necrotic  head  of  the  femur  was 
made  by  a  surgeon,  according  to  Schlichting,  in  1742  ("Philo- 
sophical Transactions,"  1742);  by  Vogel  ("Observ.  Chirurg.," 
1771),  Hoffman  ("  Vom  Scharbocke,"  1782),  Ohle  (Schmidt's 
Jaln-bucher,  B.  xi,  p.  116),  Schmalz,  and  Hedenus  ("  De  Femor. 
Amp.,"  1816,  p.  65),  but  the  first  typical  resection  was  made 
by  Anthony  White,  in  1815  (Cooper's  "Surgical  Dictionary," 
seventh  edition,  p.  272).  Mr.  White's  case  of  resection  of  the 
hip-joint  presents  more  than  ordinary  interest,  and  deserves 
to  be  fully  recorded  here :  "  John  West,  a  twin  of  delicate 
make,  was  born  and  resided  in  Westminster.  When  between 
4  and  5  years  old  he  suffered  from  scrofulous  inflammation  in 
the  left  hip-joint,  which  passed  through  the  stages  of  elongation, 
dislocation,  and  subsequent  retraction,  and  the  femur  was 
finally  lodged  in  a  very  high  position,  on  the  dorsum  of  the 


442  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

ilium.  About  three  years  subsequent  to  the  commencement  of 
the  disease,  and  when  he  was  8  years  old,  I  first  saw  him.  He 
was  much  emaciated ;  several  abscesses  had  formed,  during  tills 
period,  around  and  over  the  diseased  structures,  leaving  many 
fistulous  openings,  through  which  the  probe  easily  detected  the 
surface  of  the  displaced  bone  to  be  in  a  state  of  caries,  and 
several  small  exfoliations  had  occurred  from  the  ilium,  ischiuin, 
and  of  pubes,  over  which  bone-abscesses  had  formed.  In  the 
progress  of  the  disease  the  knee  of  the  affected  limb  had 
become  inverted  and  firmly  imbedded  on  the  lower  and  inner 
part  of  the  opposite  thigh,  from  which  position  it  could  not  be 
removed.  The  boy  being  placed  on  a  table  of  convenient 
height,  I  proceeded  to  divide  the  integuments  covering  the 
bone,  carrying  the  incision  from  an  inch  above  the  head  directly 
along  the  middle  line  of  the  bone,  about  two  inches  below  the 
trochanter ;  this  was  completed  at  one  incision,  down  to  the 
surface  of  the  bone.  The  integuments  were  dissected  inward 
and  outward,  thus  leaving  the  bone  entirely  bare  a  little  lower 
down  than  the  lesser  trochanter,  which  was  distinctly  visible. 
A  spatula  was  now  placed  under  that  part  of  the  bone  which 
was  intended  to  be  sawn  through,  so  as  to  protect  the  structure 
underneath ;  a  smaller  spatula  was  then  introduced  into  the 
space  made  by  the  saw,  and  used  as  a  lever  to  raise  the  bone, 
which,  with  a  little  dissection,  was  removed  from  the  dorsum  of 
the  ilium.  No  vestige  of  the  acetabulum  remained,  neither 
was  any  caries  of  the  ilium  discovered.  The  thigh  was  now 
readily  brought  into  a  straight  line,  and  the  knee  liberated  from 
its  position  on  the  thigh.  The  wound  was  closed  by  adhesive 
plaster,  and  no  portion  of  the  bone  was  left  exposed.  Splints 
and  an  eight-tailed  bandage  were  applied,  and  the  limb  placed 
in  a  straight  position.  The  head,  neck,  and  trochanters  were 
very  apparent,  the  caries  being  superficial,  and  not  extending 
lower  than  the  lesser  one."  The  patient  made  a  good  recovery, 
and  at  the  end  of  two  months  was  able  to  move  the  limb. 

Incision. — Straight  incision,  commencing  two  inches  above 


TUBERCULOSIS   OF    HIP-JOINT.  443 

the  trochanter,  in  the  long  axis  of  the  bone,  and  terminating 
four  to  five  inches  below  trochanter, — White,  Langenbeck, 
and  others.  A  similar,  slightly-curved  incision,  but  parallel 
to  posterior  margin  of  trochanter  major,  devised  .by  Sayre. 
A  similar  incision,  but  somewhat  more  curved,  was  made 
by  Jager  and  Textor  in  front  of  the  trochanter  major,  while 
Chassaignac  and  Ure  made  the  curve  behind.  Transverse 
incision  in  the  line  of  the  neck  of  the  femur  dividing  the 
iliacus,  sartorius,  rectus,  and  tensor  fasciae  was  recommended  by 
Roser.  It  was  the  intention  of  Roser  to  preserve  the  trochanter 
major.  This  incision  was  adopted  by  Maisonneuve  and 
Esmarch.  J.  H.  Heyfelder  combined  a  short  transverse  with 
a  long,  slightly-curved,  longitudinal  incision.  Textor  recom- 
mended two  long  longitudinal  incisions,  one  in  front  and  the 
other  behind  the  great  trochanter,  uniting  them  above,  at  the 
middle  of  the  upper  margin  of  the  great  trochanter.  Jager 
and  Ried  made  a  similar  flap,  but  with  a  more  acute  angle. 
Sedillot  and  Jones  made  a  semicircular  flap,  with  the  base 
directed  downward ;  Velpeau  a  similar  flap,  but  with  the  base 
in  the  opposite  direction.  Roux  and  Percy  recommended  a 
quadrangular  flap,  with  base  directed  upward.  The  incisions 
that  are  now  most  in  use  are :  The  straight  anterior,  straight 
over  trochanter  major,  or  along  its  posterior  border,  and  slightly 
curved  incision,  with  concavity  directed  toward  trochanter 
major. 

Modern  Operative  Technique. — Konig's  operation  of  ex- 
cision of  the  hip-joint  has  been  fully  described  in  the  chapter 
on  "  Resection."  (See  Fig.  38.)  It  is  an  operation  that  yields 
excellent  results.  In  the  same  place  was  described  an  operation 
which  is  destined,  in  the  near  future,  to  supersede  the  opera- 
tions now  usually  practiced,  and  is  best  adapted  for  all  cases  in 
which  it  is  not  deemed  necessary  to  make  a  typical  resection. 
In  this  operation  temporary  resection  of  the  trochanter  major 
is  made,  and  thus  an  important  part  of  the  upper  portion 
of  the  femur,  seldom  the  seat  of  disease,  is  preserved,  and  the 


444 


TUBERCULOSIS    OF    THE    BONES    AND    JOINTS. 


attachments  of  numerous  important  muscles  are  not  interfered 
with.  The  more  I  see  of  this  method,  and  observe  its  re- 
sults, the  more  I  appreciate  the  many  advantages  it  possesses 
over  the  operations  usually  practiced.  This  method  secures  free 
access  to  the  joint,  and  by  it  important  structures  concerned  in 
a  satisfactory  functional  result  are  preserved.  Removal  of  the 

whole  neck  and  shaft  of  the  femur 
down  to  the  trochanter  minor  will 
be  practiced  no  longer,  unless  these 
structures  are  involved  by  the 
disease.  The  modern  methods  of 


FIG.  77. — WHITE'S  POSTERIOR  CURVED 
INCISION. 


FIG.  78.— LANGENBECK'S  LONGITUDINAL 
INCISION. 


resecting  the  hip-joint  aim  at  thorough  removal  of  all  diseased 
tissue  and  conservation  of  such  portions  of  the  neck  and  shaft 
as  are  free  from  the  tubercular  process.  Efforts  in  this  direc- 
tion have  been  made  for  many  years,  but  the  operative  technique 
is  undergoing  constant  improvement,  and,  with  this  aim  in  view, 
it  is  to  be  hoped  that  the  operation  will  reach  perfection  in  the 
pear  future, 


TUBERCULOSIS   OF   HIP-JOINT. 


445 


Schede  ("  Ueber  Methodik  und  Nachbehandlung  der  Hiift- 
gelenk  resection."  Verli.  der  Deutschen  Qesellsckaftf.  Chimrgie, 
1878)  in  1878  described  his  method  of  resection  of  the  hip-joint 
by  an  anterior  incision  and  the 
decapitation  of  the  head  of  the 
femur, — an  operation  which  in 
his  hands  yielded  excellent  func- 
tional results.  It  was  generally 
believed,  at  that  time,  that  the 
removal  of  the  head  of  the  femur 
alone  would  result  in  ankylosis, 
but  Schede's  cases  demonstrated 
that  this  fear  is  not  based  on 
facts.  In  the  discussion  of 
Schede's  paper,  Hueter  spoke  in 
favor  of  the  anterior  incision,  only 


*  ^k.    '  i 

/  _  v  ,/Y    < 

V  "»*«!     .          I1.  N. 


FIG.  79.— SAYRE'S  LINE  OF  INCISION. 


FIG.  80.— M.  J.  ROBERT'S  OPERATION  OF 

EXCISION  OF  THE  HIP-JOINT. 


he  deviated  from  Schede's  method  by  making  the  incision  on  the 
outer  side  of  the  sartorius  muscle,  at  a  point  near  the  neck  of 
the  femur.  Langenbeck  laid  it  down  as  a  rule  that  if  the  head 
alone  was  affected  decapitation  should  be  done  and  all  intact 


446  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

portions  of  the  bone  preserved.  He  believed  that,  in  many 
cases,  the  head  of  the  bone  would  be  reproduced  in  the  same 
manner  as  in  Heine's  experiments  on  dogs.  He  gives  Schede's 
incision  the  preference  in  children  where  the  head  of  the  bone 
has  separated,  and  in  gunshot  wounds  of  the  hip  where  it  is 
necessary  to  remove  head  and  fragments  of  bone. 

Neuber  ("  Ueber  Hiift-und  Kniegelenk  resectionen."  Verli. 
der  Dentsclien  Geselhchaft  f.  Chirurgie,  1884)  removes  what  is 
necessary  of  the  constituent  parts  of  the  hip-joint,  after  making 
a  temporary  resection  of  the  trochanter  major.  The  trochanter 
is  exposed  by  making  au  oval  flap  with  the  base  directed  toward 
the  anterior  superior  spinous  process  of  the  ilium,  which,  with 
the  trochanter  attached,  is  drawn  in  an  upward  direction.  With 
a  hollow. chisel,  the  upper  posterior  portion  of  the  rim  of  the 
acetabulum  is  removed,  after  which  the  head  of  the  femur  can 
be  readily  dislocated  and  as  much  of  the  bone  removed  as  may 
be  necessary.  After  extirpation  of  the  diseased  capsule  the 
parts  are  replaced  in  their  normal  relations.  The  wound  is 
united  by  deep  and  superficial  sutures,  and  drainage  secured  in 
the  lower  angle  of  the  wound.  The  limb  is  kept  in  abducted 
position,  and  the  dressing  usually  allowed  to  remain  from  four 
to  six  weeks.  TCest  in  bed  and  extension  in  abducted  position 
of  limb  are  necessary  for  at  least  six  weeks.  Auto-extension 
during  the  day  and  extension  by  weight  and  pulley  at  night 
should  be  continued  for  at  least  six  months. 

Krause  ("  Ueber  die  Behandlung  mid  besonders  iiber  die 
Nacli  behandlung  der  Hiiftgelenks  resection."  Langenbeck's 
Arcldv  /.  Chirurgie,  Bd.  xxxix,  S.  466),  after  an  experience  of 
three  hundred  and  eight  resections  of  the  hip-joint  that  have  been 
performed  in  the  clinic  at  Halle,  of  which  two  hundred  and 
seventy  were  done  for  caries,  again  calls  attention  to  the  neces- 
sity of  continuing  extension  by  weight  and  pulley  for  at  least 
two  years,  during  the  night,  after  the  operation,  in  order  to  pre- 
vent unnecessary  shortening  of  the  limb.  In  children,  the 
weight  applied  varies  from  twelve  to  twenty-five  pounds.  The 


TUBERCULOSIS   OF   HIP-JOINT.  447 

limb  is  placed  in  abducted  position.  In  case  the  wound  heals 
by  primary  intention,  the  patient  is  allowed  to  leave  his  bed  at 
the  end  of  ei^ht  davs.  Passive  motion  is  advised  at  the  end  of 

O  * 

three  or  four  weeks.  The  child  is  allowed  to  walk  with  the 
assistance  of  a  walking  stool  devised  by  Volkmann  (see  p.  375), 
as  he  considers  this  preferable  to  crutches.  He  is  opposed  to 
plaster-of- Paris  dressings  and  Taylor's  apparatus.  I  have  been 
in  the  habit  of  following  Volkmann's  advice  until  the  wound 
is  healed,  after  which  I  allow  the  patients  to  walk  on  crutches, 
the  limb  suspended  by  Hutchinson's  method,  and  extension  by 
weight  and  pulley  during  the  night,  and  the  results  have  been 
such  that  I  can  strongly  recommend  this  plan  of  treatment. 

Partial  Resection  of  Head  of  Femur. — Bardenhcuer  ("  Re- 
section der  Huftgelenkspfanne  u.  partielle  Resection  des  Ober- 
schenkel  Kopfes."  Archiv  f.  kiln.  Chir.,  xlii,  p.  375)  advocates 
partial  resection  of  the  head  of  the  femur  in  cases  requiring  ex- 
cision for  tubercular  affections,  and  in  which  a  part  of  this  por- 
tion of  the  bone  can  be  saved.  He  makes  the  external  incision 
parallel  to  the  anterior  border  of  the  trochanter  major  from  ten 
to  fifteen  centimetres  in  length,  extending  at  least  ten  centimetres 
above  the  trochanter.  At  the  lower  end  of  the  incision  he  at 
once  works  his  way  down  to  the  bone,  separates  the  periosteum 
from  the  femur,  and  enters  the  joint  by  following  the  anterior 
surface  of  the  neck  of  the  femur.  The  capsule  is  then  lifted 
off  with  the  elevator,  or  cut  through  with  knife  or  scissors. 
As  soon  as  the  joint  is  freely  opened,  the  limb  is  strongly 
rotated  outward  so  as  to  dislocate  the  bone  in  a  forward 
direction.  Tli9  affected  portion  of  bone  can  now  be  removed, — 
a  process  which  Bardenheuer  calls  concentric  resection.  The 
capsule  is  extirpated,  and  if  the  acetabulum  is  affected  it  is 
cleared  out  with  a  sharp  spoon.  During  the  operation  the  limb 
is  changed  in  position  so  as  to  render  all  parts  of  the  joint 
accessible.  He  reports  a  number  of  successful  cases  operated 
on  by  this  method. 

Proper  mechanical  treatment,  after  partial  resection  of  the 


448  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

hip-joint,  is  essential  in  obtaining  speedy  healing  of  the  wound 
and  in  securing  a  satisfactory  functional  result. 

Results. — The  immediate  and  remote  results  are  greatly 
influenced  by  the  pathological  conditions  within  and  around  the 
hip-joint,  as  well  as  the  age  and  general  condition  of  the  patient. 
A  granulating  synovitis,  with  or  without  osseous  foci,  in  an 
otherwise  healthy  child,  presents  the  most  favorable  conditions 
for  a  speedy  healing  of  the  wound  and  a  good  functional  result. 
Operations  on  suppurating  hip-joints  are  seldom  followed  by 
primary  healing  of  the  wound,  and  this  is  often  only  accom- 
plished after  weeks  and  months  of  profuse  suppuration.  In 
cases  of  this  kind,  it  often  becomes  necessary  to  make  additional 
provisions  for  drainage,  and  to  scrape  out  fistulous  tracts  before 
the  wound  finally  heals.  The  shortening  varies  from  a  few 
lines  to  a  number  of  inches.  If  shortening  does  not  exceed  an 
inch  and  a  half  the  functional  result  is  usually  satisfactory.  If 
the  epiphysis  is  removed  in  young  children  progressive  shorten- 
ing is  very  liable  to  follow. 

A  suppurating  hip-joint  in  adults  warrants  a  grave  prog- 
nosis. Anaemic  patients  and  patients  suffering  from  tubercu- 
losis of  other  organs,  or  other  serious  complicating  disease,  are 
bad  subjects  for  operative  interference. 

In  the  classical  monograph  on  resections  by  Heyfelder, 
published  in  1863  ("  Lehrbuch  der  Resectionen."  Wien,  1863), 
seventy-one  cases  of  resection  of  the  hip-joint  are  tabulated,  and 
we  find  it  stated  that  in  thirty-three  the  operation  proved  fatal. 
Boeckel  reported  thirty-four  cases  of  resection  of  the  hip-joint; 
of  this  number  twenty-two  recovered  and  twelve  died.  The 
immediate  causes  of  death  in  these  cases  were :  shock,  3  ;  men- 
ingeal  tuberculosis,  4 ;  exhaustion  shortly  after  operation,  2 ; 
pelvic  tuberculosis,  2;  diphtheria,  1.  Of  the  cases  that  recov- 
ered from  the  operation,  2  were  lost  sight  of  after  a  year;  2  died 
of  tubercular  meningitis, — 1  three  months  and  the  other  six 
years  after  operation  ;  2  died  of  albuminuria  two  and  three  years, 
respectively,  after  operation.  Of  the  9  that  were  living  at  the 


TUBERCULOSIS   OF   HIP-JOINT. 


449 


time  the  report  was  made, — eighteen  months  to  ten  years  after 
operation, — in  5  fistula-  existed,  and  only  in  9  was  the  wound 
permanently  healed. 

Elben  ("  Ueber  die  Gebrauchsfahigkeit  der  Extremitat 
nach  der  Resection  im  Hiiftgelenk."  Dissertation,  Wiirzburg, 
1878)  studied  the  final  functional  result  in  sixty-one  cases  of 
resection  of  the  hip-joint.  In  five  of  these  cases  the  limb  was 


FIG.  81.— RESECTION  OF  HIP-JOINT  FOUR 

MONTHS  AFTER  OPERATION. 

(Bar-well.) 


Fio.  82.— RESECTION  OF  HIP -JOINT  TWELVE 

YEARS  AFTER  OPERATION. 

(Bar  well.) 


useless.  Fifteen  patients  could  walk  aided  by  mechanical  sup- 
port, and  forty-one  had  good  use  of  the  limb  and  could  walk 
without  assistance. 

The  more  conservative  operations  on  the  hip-joint,  in  the 
operative  treatment  of  tubercular  affections,  that  are  now  grad- 
ually displacing  typical  resection  will  yield  more  satisfactory 
functional  results,  while  the  thoroughness  with  which  osseous 


450 


TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 


foci,  the  diseased  capsule,  and  infected  para-articular  tissues  are 
now  being  removed  will  be  less  frequently  followed  by  local 
recidivation. 

Resection  of  Acetabulum.  —  Resection  of  the  acetabulum 
for  tubercular  disease  was  devised  by  Schmid,  of  Stettin,  and 
first  practiced  by  him  on  the  living  human  subject  June  20, 
1890.  (James  Kellogg,  "  Resection  of  Acetabulum."  Nashville 
Journal  of  Medicine  arid  Surgery,  June,  1891.)  The  patient 
was  a  boy,  aged  7  years,  whose  hip-joint  was  resected  on  the 
5th  of  August,  1889,  after  being  a  sufferer  from  tubercular 

coxitis  for  two  years.  Soon  after  the 
operation  fistulae  formed  and  suppu- 
ration set  in,  and  the  boy  became 
greatly  emaciated  from  the  hectic 
fever  and  profuse  purulent  discharge. 
Scraping  of  the  cavity  proved  of  no 
avail.  At  the  time  mentioned,  ampu- 
tation through  the  hip-joint  was 
made  by  the  bloodless  method  as  a 
preliminary  step,  whereupon  the  ace- 
tabulum was  freely  exposed  by  an 
incision  over  it  and  removed  by  saw- 
ing through  the  os  innominatum  in 
FIG.  83.— RESECTION  OF  ACETABC-  three  places,  beginning  at  the  hori- 

I.UM.    SECTIONS  THROUGH  BONE. 

zontal  ramus  of  the  os  pubes,  which 

called  for  an  incision  parallel  to  the  horizontal  ramus  of  the  os 
pubes,  and  at  a  right  angle  to  the  first  incision.  The  large 
vessels,  together  with  the  flap  of  the  soft  parts,  were  easily 
pushed  out  of  the  way,  whereupon  the  ischium  was  sawn 
through,  and,  finally,  the  acetabulum  was  detached  by  sawing 
through  the  ilium  at  the  desired  point.  The  instruments  used 
in  making  the  sections  were  pistol-saw,  chain-saw,  hammer  and 
chisel.  The  acetabulum,  being  now  free,  was  separated  from 
the  pelvic  fascia,  while  the  large  cavity  resulting  was  stuffed 
with  iodoform  gauze.  The  haemorrhage  was  moderate. 


-  Ds-rp    _ 

TUBERCULOSIS   (Jff^H^ JOINT.  '45  J/- 

Tf^Si/ftfi 

Suppuration  ceased  after  the  operation  and  the  general 
condition  of  the  patient  improved.  One  small  fistula  which 
remained  soon  healed.  The  soft  parts  have  produced  a  stump 
almost  as  large  as  the  stump  resulting  from  a  high  amputation  of 
the  thigh,  which  permits  the  application  of  a  leather  case  to  which 
an  artificial  limb  is  attached.  The  patient  is  able  to  walk  well 
without  crutch  or  cane.  The  second  case,  a  girl  aged  14  years, 
with  tubercular  coxitis,  was  resected  August  27,  1889,  and  on 
March  4,  1890,  the  thigh  was  amputated  through  the  hip-joint 
for  similar  reasons  as  in  the  first  case.  On  August  20,  1890, 
the  acetabulum  was  resected.  The  condition  of  the  patient  pre- 
vious to  the  operation  was  far  worse  than  in  the  preceding  case. 
After  the  operation  improvement  followed  promptly  until  the 
child  was  restored  to  perfect  health. 

The  third  case,  a  boy  aged  13  years,  was  admitted  into  the 
hospital  September,  1890,  and  resection  was  made  at  once  for 
tubercular  coxitis  of  two  years' duration.  The  operation  proved 
a  failure,  and  on  the  26th  of  November  the  acetabulum  was 
resected  without  amputation  of  limb.  It  was  found  that  the 
disease  was  limited  to  this  structure.  Union  of  wound  by 
primary  intention.  Five  weeks  after  the  operation  the  boy  was 
able  to  walk  about  alone  without  crutches. 

Bardenheuer  ("  Resection  d.  Hiift  gelenkspfanne,"  etc. 
Archiv  f.  klin.  Chirurgie,  B.  xlii,  p.  375)  resects  the  acetabulum 
through  an  extra-peritoneal  incision  extending  in  a  downward 
direction  as  far  as  the  junction  of  the  middle  with  the  outer 
third  of  Poupart's  ligament.  The  vessels  and  other  soft  parts 
are  drawn  out  of  the  way  by  retractors ;  the  periosteum  over 
the  portion  of  bone  corresponding  with  the  acetabulum  is  sep- 
arated and  the  bone  removed  with  a  sharp  chisel.  If  he  make, 
at  the  same  time,  a  partial  resection  of  the  head  of  the  femur, 
what  remains  of  this  is  fixed  in  the  defect,  and  in  several  cases 
he  obtained,  by  a  combination  of  these  two  operations,  excellent 
functional  results, — movable,  useful  limbs. 


CHAPTER  XXXVI. 

TUBERCULOSIS  OF  KNEE-JOINT. 

OF  the  large  joints  the  knee-joint  is  most  frequently  the 
seat  of  tubercular  disease,  and  is  next  in  frequency  to  tubercular 
spondylitis.  The  description  of  the  old  authors  of  tumor  albus 
apply  to  this  joint.  It  is  also  in  this  joint  that  tubercular  pro- 
cesses have  been  studied  with  the  greatest  care  and  thorough- 
ness from  etiological,  clinical,  and  pathological  stand-points. 
The  description  of  tubercular  joints,  as  found  in  text-books,  is 
taken  from  the  clinical  appearances  and  pathological  conditions 
of  this  joint  when  the  seat  of  a  tubercular 
affection. 

Age  and  Primary  Location  of  Dis- 
ease. —  Although  no  age  is  exempt  from 
tuberculosis  in  this  locality,  children  and 
young  adults  furnish  the  largest  number  of 
cases.  In  reference  to  the  location  of  the 
primary  disease  in  this  joint,  Willemer's 
("Ueber  Kniegelenk  tuberculose."  Deutsche 
Zeitsclirift  f.  Cliirurgie,  B.  xxii,  p.  268) 
investigations  show  that  in  patients  less 
than  10  years  of  age  it  primarily  attacks 
the  sy  no  vial  membrane  in  39  per  cent.,  and 
in  61  per  cent,  one  or  both  of  the  articular  extremities  are  the 
primary  starting-points;  between  10  and  20,  49  per  cent,  are 
synovial  and  51  per  cent,  osseous;  above  20  years  of  age,  33 
per  cent,  are  primarily  synovial  and  65  per  cent,  primarily 
osseous. 

In  114  museum  specimens  Konig  found  that  69  were 
primarily  osseous,  33  synovial,  and  12  doubtful.  He  states 
that,  in  his  own  experience,  the  two  forms  are  about  equally 
frequent  in  youth,  but  in  the  aged  there  are  three  times  as 
many  osseous  cases  as  synovial.  Of  43  cases  examined  by 
(452) 


FIG.  M.— TUBERCULAR 
•SYNOVITIS  OF  THE  KNEE- 
JOINT,  WITH  EFFUSION. 


TUBERCULOSIS   OF    KNEE-JOINT. 


453 


Cheyne  (British  Medical  Journal,  April  4,  1891),  16  were  found 
to  be  synovial,  5  very  probably  sy  no  vial,  2  doubtful,  and  20 
osseous.  In  only  2  of  tbe  osseous  cases  were  multiple  foci 
present ;  in  all  tbe  rest  only  one  focus  was  found.  Sequestration 
was  found  only  in  7  of  tbe  osseous  cases.  In  the  osseous  form 


FIG.  85.— TUBERCULAR  OSTEOMYELITIS  OF  INTERNAL  CONDYLE  OF  FEMUR. 

of  knee-joint  tuberculosis  tbe  primary  disease  in  the  bone  attacks 
most  frequently  the  epiphysis  itself.  Tbe  extension  of  the 
disease  beyond  the  epiphysial  line  is  unusually  rare. 

The   internal   condyle  of  tbe   femur   is   most   frequently 
affected,  then  the  head  of  tbe  tibia,  and  least  in  frequency  the 


FIG.  86.— TUBERCULAR  OSTEOMYELITIS  OF  BOTH  CONDYLES  OF  FEMUR. 

patella.  Kummer  ("  L'extirpation  totale  de  la  rotule."  Revue 
Suisse  Rom.,  Xo.  11,  1889)  reports  a  case  of  extirpation  of  tbe 
patella  for  primary  tuberculosis  of  this  bone.  The  patient  was 
25  years  of  age,  who  for  three  years  had  suffered  from  abscess 
in  the  region  of  the  patella,  followed  by  permanent  fistulous 


454 


TUBERCULOSIS   OF    THE    BONES    AND   JOINTS. 


openings.  The  patella  was  extirpated  through  a  longitudinal 
incision,  and,  as  the  synovial  membrane  on  its  under  surface 
appeared  to  be  intact,  the  joint  was  closed  by  suturing  the 
ligamentum  patella  with  silk  on  the  one  side  to  the  fascia  lata, 
and  on  the  other  to  the  fibrous  end  of  the  vastus  interims,  and 
the  skin  was  separately  closed  with  sutures.  Limb  placed  upon 
posterior  splint  in  extended  position.  Primary  union.  Restora- 
tion of  function  almost  perfect  in  the  course  of  time.  He  re- 
ports at  the  same  time  three  similar  cases  from  Kocher's  clinic. 


FIG.  87.— CAKIES  NECROTICA  OF  TIBIA  (DIASTASIS). 

In  one  patient  extirpation  of  patella  and  bursa  of  quadriceps, 
followed  by  ankylosis.  In  two  cases  evidement  had  to  be 
followed  by  resection  of  knee.  Three  additional  cases  are  re- 
ported by  Kaufmann.  Kummer  believes  extirpation  should  be 
done  if  disease  is  limited  to  bone.  Evidement  not  satisfactory 
in  its  results.  In  many  of  these  cases  the  disease  is  located 
immediately  underneath  the  articular  cartilage,  and  invasion  of 
the  joint  is  an  early  occurrence.  In  this  joint  Kocher  asserts 
he  has  observed  primary  tuberculosis  of  the  semilunar  cartilages. 


TUBERCULOSIS   OF   KNEE-JOINT.  455 

Of  all  joints  the  knee-joint  is  best  adapted  for  successful  treat- 
ment by  Ultra-articular  injections,  and  this  method  of  treatment 
should  receive  a  fair  trial  before  arthrectomy  or  resection  is 
undertaken.  It  can  be  employed  with  good  prospects  of  a 
favorable  result  in  all  cases  of  primary  tuberculosis  of  the  syno- 
vial  membrane,  and  in  secondary  tuberculosis  of  this  structure 
caused  by  small  osseous  foci,  as  long  as  the  disease  remains 
subcutaneous.  Large  osseous  foci  caseating  or  sequestrating, 
as  well  as  suppurating  knee-joints,  indicate  resection. 

RESECTION    OF   KNEE-JOINT. 

History  of  Operation. — Filkin,  of  Northwich  (Journ.  de 
Med.,  vol.  Ixxxiv,  p.  400)  resected  the  knee-joint  successfully 
in  1762,  and  the  patient  survived  the  operation  for  twenty 
years.  This  case,  however,  did  not  appear  in  print  until  Park, 
of  Liverpool,  made  the  same  operation  and  published  an  ac- 
count of  his  case,  in  1782.  In  the  year  1781,  Park,  of  Liver- 
pool, resected  the  articular  extremities  of  the  knee-joint  and  re- 
moved the  patella  in  the  case  of  Hector  McCaghen,  aged  33,  on 
account  of  caries  of  ten  years'  standing.  He  made  a  crucial 
incision  on  the  fore  part  of  the  knee,  and  found  no  difficulty  in 
sawing  off  the  ends  of  the  bones.  The  patient  made  a  tedious 
recovery,  but  finally  obtained  a  useful  limb.  As  to  the  ultimate 
result,  we  will  let  Mr.  Park  speak  for  himself:  "  On  the  whole, 
from  what  I  have  now  seen  of  this  man's  limb,  I  do  not  hesitate 
to  declare  that  it  appears  to  me  so  much  more  valuable  than 
any  artificial  one  that,  was  I  in  his  situation,  should  infinitely 
prefer  the  former  at  the  price  which  he  has  obtained  it."  Mr. 
Park,  originator  of  resection  of  the  knee,  with  characteristic 
modesty,  insists,  in  the  letter  in  which  he  describes  his  new 
operation  to  Mr.  Pott,  "I  am  conscious  that  the  mode  of  oper- 
ating which  I  have  described  is  by  no  means  perfect,  but  still 
stands  in  need  of  the  finishing  hand  of  a  more  able  master." 
Park's  case  was  one  of  tubercular  disease,  who  recovered  so 
perfectly  that  he  was  able  to  follow  the  occupation  of  a  sailor. 


456 


TUBERCULOSIS   OF   THE    BONES   AND   JOINTS. 


Moreau  made  the  operation  in  France  in  1792,  and  Mulder 
in  Holland  in  1809.  Jaeger  performed  the  operation  for  the 
first  time  in  Germany  in  1830,  and  his  example  was  followed  by 
Fricke  and  Textor.  The  first  operation  of  this  kind  in  America 
was  performed  by  Buck  in  1844. 

Incision.— A  crucial  incision  over  the  knee  was  made  by 
Park  in  his  first  case.  A  straight  incision  over  the  outer  side 

of  the  joint  was  practiced  by 
Chassaignac.  A  transverse  in- 
cision below  the  patella  was 
recommended  by  Sauson  and 
Begin.  Textor  modified  this 
incision  by  giving  it  a  slight 
curve.  Fergusson  preferred  a 
straight  transverse  incision. 
Two  longitudinal  incisions,  one 
on  the  outside  and  the  other  on 
the  inside  of  the  patella,  were 
made  by  Jeffray  and  Sedillot. 
Guepratte  and  Erichsen  in- 
creased the  length  and  curve  of 
Textor's  incision  and  made  an 
anterior  semicircular  flap  with 
the  convexity  directed  down- 
ward. Moreau  connected  Sedil- 
FIG.  88,-ANTERioR  CURVED  INCISION,  lot's  longitudinal  incisions  by  a 

CONVEXITY  OF  FLAP  DIRECTED  UPWARD. 

transverse  cut  across  the  centre 

of  the  patella,  thus  making  two  flaps, — a  method  which  was 
adopted  by  Fergusson  and  Langenbeck.  Jager  made  the  inci- 
sion in  front  across  the  joint,  and  after  opening  the  joint  made 
a  longitudinal  incision  as  required  in  each  case.  Humphrey 
made  a  transverse  incision,  but  above  the  patella.  Billroth 
resorted  to  a  straight,  anterior  incision  over  the  centre  of  the 
patella  and  sawed  the  articular  ends  obliquely,  so  that  the  sur- 
faces, on  being  brought  into  apposition,  would  overlap  each  other. 


TUBERCULOSIS   OF   KNEE-JOINT.  457 

Resection  and  arthrectomy  of  the  knee-joint  by  an  anterior 
semilunar  flap  with  convexity  directed  upward  and  transverse 
section  of  the  patella  are  fully  described  in  the  chapter  on 
"Resection." 

Riedinger's  central  vertical  incision  and  section  of  patella 
in  same  direction  and  Volkmann's  transverse  incision  and  trans- 
verse section  of  patella  are  well  known,  and  have  been  frequently 
employed  both  for  arthrectomy  and  excision  of  the  knee-joint. 

Modern  Operative  Technique.  —  Reinke  (Aus  der  chir. 
Klinik  zu  Bonn.  "  Ueber  die  Resection  des  Kniegelenks." 
Dissertation.  Bonn,  1888)  gives  a  description  of  the  method 
of  resection  of  the  knee-joint  as  devised  by  Trendelenbnrg.  The 
incision  of  the  skin  extended  from  one  condyle  to  the  other, 
with  the  convexity  directed  upward.  A  short,  longitudinal  in- 
cision is  made  to  meet  the  centre  of  the  concavity,  and  the  flaps 
thus  made  are  dissected  up  and  reflected. 

The  tendon  of  the  quadriceps  is  divided  transversely,  which 
exposes  the  fungous  capsule  freely.  If  a  typical  resection  is  to 
be  made,  the  condyles  are  removed  and,  after  division  of  the 
tendon  of  the  patella,  the  tibia  is  sawn  through  and  capsule 
with  patella  and  articular  extremities  removed  without  further 
dissection.  The  bones  are  brought  in  apposition  and  fixed  with 
aseptic  ivory  nails,  and  drainage  secured  and  fixation  dressing 
applied.  In  five  years  fifty-two  resections  were  made  by  Trendel- 
enburg  by  this  method.  Of  this  number  five  died,  and  in  seven 
cases  amputation  became  necessary  later,  of  which  number 
three  proved  fatal.  Healing  by  firm  ankylosis  in  extended 
position  without  fistulous  openings  attained  forty  times;  with 
firm  ankylosis,  but  fistulae,  nine  times;  without  firm  ankylosis, 
three  times.  Oilier  ("  Resection  du  genou."  Lyon  Medicale,  1888, 
p.  497)  in  1888  reported  fifty  resections  of  the  knee-joint,  the 
whole  number  done  by  himself.  He  recommends  that  the  first 
dressing  should  not  be  changed  before  the  expiration  of  from  forty 
to  fifty  days.  He  uses  rubber  drains,  but  believes  that  in  mild 
cases  absorbable  drains  would  answer  the  purpose.  He  is  of 


458 


TUBERCULOSIS   OF   THE    BONES    AND   JOINTS. 


the  opinion  that  erasion  or  arthrectomy  will  only  succeed  in 
children ;  in  adults  this  procedure  is  followed  by  local  relapses. 
Neuber  ("  Ueber  Hiift-und  Kniegelenk  resectionen."  Verh.  der 
DeuiscJien  Gesellscliaft  /.  Chirurgie,  1884)  exposes  the  patella 
and  knee-joint  by  an  anterior  curved  incision,  with  the  base 
directed  upward. 

The  articular  ends  of  the  femur  and  tibia  are  sawn  off,  as 
well  as  the  under  surface  of  the  patella.  The  anterior  surface 
of  the  lower  end  of  the  femur  and 
upper  end  of  tibia  are  also  sawn  off 
sufficiently  far  so  that  the  space  cor- 
responds with  the  under  resected  sur- 
face of  the  patella.  After  extirpation 


FIG.  89. — OLLIEB'S  INCISION. 


FIG.  90.— MACKENZIE'S  ANTERIOR 
CURVED  INCISION. 


of  the  capsule  the  soft  tissues  in  the  popliteal  space  are  stitched 
to  the  posterior  surface  of  the  tibia  and  the  condyles  of  the 
femur.  The  tibia  and  femur  are  brought  in  apposition  and 
fastened  together  with  two  nails.  The  patella  is  nailed  to  the 
vivified  surfaces  of  the  tibia  and  femur,  and  the  cutaneous  flap 
replaced  and  sutured.  Drainage  is  established  at  the  most 
dependent  point  of  the  wound  by  suturing  the  skin  to  the  deep 
para-articular  tissues. 


TUBERCULOSIS   OF    KNEE-JOINT.  459 

Hahn  ("  Ueber  Kniegelenksresection."  Verh.  der  Deutschen 
Qeselhchaft  f.  Chirurgie,  1882)  renders  the  limb  bloodless  with 
Esmarch's  constrictor,  and,  while  it  is  kept  in  the  extended  posi- 
tion, he  makes  his  incision  by  cutting  from  a  point  corresponding 
with  the  lowest  part  of  the  articulation  on  the  inner  side,  carry- 
ing the  knife  to  the  upper  margin  of  the  patella  and  across  the 
limb  to  a  point  on  the  opposite-  side  of  the  joint  where  the 
incision  was  started.  (Fig.  88.)  This  curved  incision,  with  the 
convexity  directed  upward,  divides  all  the  structures  down  to 
the  bone,  including,  of  course,  the  tendon  of  the  quadriceps 
muscle.  By  flexing  the  leg  forcibly  the  whole  of  the  interior 
portion  of  the  joint  is  freely  exposed.  The  synovial  membrane 
is  made  freely  accessible  by  this  incision,  and  the  affected  artic- 
ular extremities  can  also  be  thoroughly  dealt  with.  For  fixa- 
tion of  the  resected  ends  he  uses  from  two  to  three  steel  nails, 
which  are  inserted  through  the  skin  and  driven  through  the 
tuberosity  of  the  tibia  well  into  the  resected  end  of  the  femur. 

Whenever  it  is  possible  to  avoid  a  typical  resection  of  the 
knee-joint  this  should  be  done,  and  the  removal  of  tissue  limited 
to  the  diseased  areas.  In  atypical  resection  of  this  joint  the 
chisel  is  a  better  instrument  than  the  saw. 

The  following  case  illustrates  a  chisel  resection  of  the 
knee-joint : — 

Tuberculosis  of  Knee- Joint ;  Resection;  Recovery. — J.  H., 
male,  17  years  of  age,  was  admitted  into  the  Milwaukee  Hos- 
pital, April  5,  1890,  with  the  following  history:  At  the  age  of 
G  he  fell  from1  a  tree  and  injured  his  left  knee ;  some  stiffness 
of  the  joint  remained,  but  not  to  such  an  extent  as  to  incon- 
venience him  much ;  about  one  year  ago  he  sustained  a  second 
injury  to  the  same  knee,  which  was  followed  by  a  painless 
enlargement  of  the  articulation,  except  latterly,  on  walking,  but 
for  the  past  month  the  pain  has  been  constant.  No  hereditary 
history  of  tuberculosis  in  his  family. 

Present  Condition. — Patient  anaemic ;  slight  rise  of  tem- 
perature at  night ;  pulse  small  and  weak ;  knee  ankylosed  and 


460  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

enlarged,  with  the  point  of  fluctuation  to  the  inner  side  of  the 
patellar  tendon,  which  is  also  the  point  of  greatest  tenderness. 

Operation. — Vertical  incision  over  the  point  of  fluctuation 
was  followed  by  the  escape  of  tubercular  pus.  Digital  explora- 
tion of  the  cavity  showed  that  it  communicated  with  the  joint, 
which  )vas  opened,  by  the  usual  transverse  incision,  for  resec- 
tion. An  atypical  chisel  resection  of  the  ends  of  the  bones  was 
made,  during  which  three  tubercular  depots  were  found  in  the 
head  of  the  tibia  and  one  in  the  inner  condyle  of  the  femur. 
Of  those  in  the  head  of  the  tibia,  two  were  situated  in  the  inner 
half  and  one  in  the  outer.  In  the  former  tubercular  necrosis 
had  occurred,  and  in  the  latter  a  triangular  sequestrum  was 
surrounded  by  sclerosed  bone.  When  these  had  been  removed 
there  remained  two  cavities,  each  the  size  of  a  walnut,  that  on 
the  inner  side  being  divided  into  two  parts  by  a  septum  of 
sclerosed  bone,  and  extending  downward  for  about  one  inch  and 
a  half  into  the  shaft  to  opposite  the  lower  angle  of  the  vertical 
incision  ;  that  in  the  condyle  was  the  size  of  a  hazel-nut.  All 
these  were  packed  with  decalcified  bone-chips  before  the  bones 
were  brought  into  apposition ;  provision  was  made  for  drainage 
by  strands  of  catgut  introduced  at  the  angles  of  the  transverse 
incision  and  at  the  lowest  point  of  the  vertical;  incisions  closed 
by  deep  sutures  of  catgut  and  superficial  of  silk.  On  the  follow- 
ing day  the  dressing,  having  become  saturated  by  sero-sanguin- 
eous  discharge,  was  changed.  The  second  change  of  dressing 
was  made  twenty-four  days  thereafter,  when  the  incisions  were 
found  completely  healed  ;  the  drain  opening  at  the  lower  angle 
of  the  vertical  incision  was  closed  by  an  aseptic  blood-clot ;  the 
site  of  the  cavity  in  the  head  of  the  tibia  was  firm  on  the  level 
of  the  surrounding  bone  and  painless  on  pressure  ;  bony  consol- 
idation between  the  resected  ends  had  commenced.  The  sutures 
were  removed  and  a  light  fixation  dressing  of  plaster  of  Paris 
applied,  which  was  not  removed  until  complete  bony  union 
between  resected  ends  had  taken  place.  Patient  has  been  in 
good  health  since.  Shortening  of  limb  slight.  Walks  several 


TUBERCULOSIS   OF    KNEE-JOINT.  461 

miles  daily  without  any  inconvenience,  and  with  only  a  slight 
limp. 

Direct  Fixation  of  Resected  Ends. — In  order  to  obtain 
bony  union  in  good  position  and  in  the  shortest  possible  space 
of  time,  surgeons  have  resorted  for  some  time  to  direct  fixation 
of  the  resected  ends  by  suturing  or  nailing  them  together. 

The  objects  of  this  procedure  are  to  secure  accurate  and 


FIG.  Ql.—DRiLr,,  AND  BONE-NAILS  FOR  DIRECT  FIXATION  OF  FRAGMENTS 
AFTER  RESECTION  OF  THE  KNEE-JOINT.    (Bryant.) 

uninterrupted  coaptation  of  the   sawn  surfaces  and  to  effect 
perfect  immobilization. 

The  importance  of  preserving  the  epiphysial  cartilages  in 
resection  of  the  knee-joint  in  children  has  been  repeatedly 
referred  to.  The  removal  of  one  or  even  both  epiphysial 
cartilages  of  the  knee-joint  in  young  children  is  sure  to  result 
in  great  shortening  of  the  limb.  The  tibia  and  femur  have 
been  fastened  together  by  nails  of  iron,  steel,  ivory,  or  bone, 


462  TUBERCULOSIS   OF    THE    BONES    AND    JOINTS. 

which  have  been  driven  through  the  upper  end  of  the  tibia 
deeply  into  the  condyles  of  the  femur.  Absorbable  nails,  such 
as  aseptic  bone  or  ivory  nails,  have  been  buried  and  left  perma- 
nently in  the  tissues  to  be  removed  by  absorption,  while  metallic 
nails  were  left  in  situ  until  the  resected  ends  were  united  by  a 
bony  callus  sufficiently  firm  to  render  this  mechanical  support 
superfluous. 

Morrant  Barker  ("  A  Method  of  Fixing  the  Bones  in  the 
Operation  of  Excision  of  the  Knee-Joint."  British  Medical 
Journal,  1887,  p.  321)  transfixes  the  upper  end  of  the  tibia  and 
the  lower  end  of  the  femur  with  two  steel  needles,  which  are 


FIG.  92.— EPIPHYSIAL  CARTILAGE  AND  LINE  OF  SECTION  IN  EXCISION  OF 
KNEE-JOINT.    (Bryant.) 

made  to  cross  each  other  in  the  shape  of  a  St.  Andrew's  cross. 
(Fig.  39.) 

Willet  and  Marsh  ("  Remarks  on  a  Method  of  Fixing  the 
Bones  in  the  Operation  of  Excision  of  the  Knee- Joint."  British 
Medical  Journal,  p.  389,  1887)  used,  for  the  same  purpose,  nails 
made  of  crocheting  needles.  Stoker  ("  On  Some  Elements  of 
Success  in  Excision  of  the  Knee-Joint."  Dublin,  Journal  of 
Medical  Science,  July,  1887),  Sir  William  Stokes,  Corley,  Thom- 
son, and  Franks  use  nails  made  of  strong  silver  wire,  which  they 
remove  after  three  weeks.  The  use  of  direct  means  of  fixation 
of  the  resected  ends  in  resection  of  the  knee-joint  is  being  grad- 
ually abandoned.  If  the  limb  is  well  supported  by  a  circular 


TUBERCULOSIS    OF   KNEE-JOINT.  463 

plaster-of-Paris  splint  or  a  posterior  suspension  splint,  accurate 
apposition  of  the  sawn  surfaces  and  perfect  immobilization  of 
the  limb  are  maintained  almost  to  perfection,  rendering  the  use 
of  fixation  nails  or  sutures  unnecessary.  The  use  of  proper 
mechanical  support  should  not  be  dispensed  with  until  the  re- 
sected ends  have  been  united  by  an  osseous  callus,  which  will 
require,  according  to  the  age  and  general  condition  of  the  patient, 
from  six  weeks  to  three  months. 

Ivory  Joint. — At  the  Berlin  International  Medical  Con- 
gress, Gluck  ("  Die  Invaginations  Methode  der  Osteo-arthro- 
plastik."  Berl  kiln.  Wochenschrift,  No.  32,  1890)  read  a 
paper  and  gave  several  demonstrations  of  a  method  of  his  own 
device,  by  which  he  claims  that  it  is  possible 
to  implant  successfully,  between  the  resected 
ends,  not  only  portions  of-  bone,  but  even 
whole  joints.  Among  others,  he  showed  a 
patient  whose  knee-joint  had  been  excised 
and  an  ivory  joint  inserted.  The  wound  had 
completely  healed,  and  the  patient  was  ca- 
pable of  flexing  and  extending  the  joint 
through  an  angle  of  nearly  forty-five  degrees 
without  any  pain  or  serious  inconvenience.  FIIVOBY  JOINT 
When  the  ends  of  the  bones  have  been  sawn 
off  in  the  usual  manner,  the  medullary  cavity  is  scraped  out  for 
a  certain  distance,  and  a  plug  of  the  shape  indicated  in  Fig.  93 
is  inserted  and  firmly  fixed  in  its  place.  It  is  perforated,  so  as 
to  allow  the  surrounding  living  tissues  to  find  access  into  its 
interior.  The  bone  on  the  opposite  side  is  similarly  hollowed 
out  and  the  same  kind  of  a  plug  inserted  into  its  interior;  the 
two  are  then  united  in  such  a  manner  that  the  two  pieces  of 
ivory  work  upon  one  another  like  a  hinge.  It  was  generally 
predicted  at  the  time  that  the  results  claimed  by  Gluck  would 
not  turn  out  favorably  in  the  end.  This  proved  to  be  the  case. 
In  the  cases  in  which  the  wound  healed  by  primary  intention 
over  the  foreign  body,  this  was  removed  later  by  absorption 


464  TUBERCULOSIS    OF   THE   BONES    AND    JOINTS. 

or  gradually  found  its  way  to  the  surface,  as  has  been  shown 
later  by  von  Bergmann.  The  procedure  has  even  now  only  an 
historical  interest. 

Results. — It  is  interesting  to  know  something  definite  of 
the  early  results  of  resection  of  the  knee-joint  with  an  imperfect 
technique  and  no  antiseptic  precautions  whatever. 

Of  the  first  seventeen  cases  of  resection  of  the  knee-joint 
made  by  Filkin,  Park,  the  two  Moreaus,  Mulder,  Fricke,  Roux, 
Textor,  Crampton,  and  Syme  between  the  years  1761  and  1830, 
and  tabulated  by  Price  ("  A  Description  of  the  Diseased  Con- 
ditions of  the  Knee- Joint,"  etc.,  p.  58.  London,  1865),  six 
were  cured  and  had  useful  limbs,  ten  died,  and  one  recovered, 
but  the  limb  was  useless. 

Of  a  later  series  of  nine  cases  operated  on  by  Jager,  Textor, 
Lombardo,  and  Heusser,  five  were  cured  with  useful  limbs,  three 
died  from  the  effects  of  excision,  and  one  after  amputation  had 
been  adopted  on  account  of  failure  of  excision  of  the  joint. 

Of  twenty-one  cases  of  excision  of  the  knee-joint  which 
occurred  in  the  practice  of  Mr.  Fergusson.  also  quoted  by  Mr. 
Price,  nine  were  cured  with  useful  limbs,  the  degree  of  utility- 
varying,  however,  according  to  circumstances,  and  eleven  died. 
Taking  all  of  the  earlier  operations  on  the  Continent  and  in 
America,  the  mortality  is  nearly  50  per  cent. 

Sad  statistics  of  knee-joint  resections  are  given  by  Heineke 
("  Beitrage  zur  Kenntniss  und  Behandlung  der,  Krankheiten 
des  Knies,"  p.  240.  Danzig,  1866).  He  reports  eleven  cases 
of  this  operation  from  the  clinic  at  Greifswald,  and  of  these  only 
four  resulted  successfully ;  in  the  rest  the  operation  proved  fatal. 

Hornung  ("  Ueber  Resection  des  Kniegelenks  mit  einem 
Falle  von  doppelseitiger  Kniegelenkresection."  Dissertation. 
Wiirzburg,  1887)  informs  us  of  the  final  result  in  a  case  of  re- 
section of  both  knee-joints  in  the  same  patient  made  by  Maas. 
The  patient  was  able  to  walk  and  climb  hills  witli  great  facility. 
The  author  gives,  at  the  same  time,  an  account  of  seventy-one 
resections  of  the  knee-joint  in  the  clinic  at  AViirzburg,  made 


TUBERCULOSIS    OF    KNEE-JOINT.  465 

during  the  service  of  Maas,  from  1877  to  1886.  Subsequent 
treatment  by  amputation  became  necessary  in  thirteen  cases. 

Oilier  (-'  Sur  la  resection  du  Genou."  Bull,  de  V Acad- 
emic,  No.  20,  1889)  calls  attention,  in  this  paper,  to  the  fact 
that  resection  of  the  knee-joint  is  not  popular  in  France  at  the 
present  time,  as  some  surgeons  in  that  country  do  not  resort  to 
it  even  now.  He  performed  the  operation  up  to  the  year  1870 
seventeen  times,  and  all  patients  but  one  died.  Since  the  intro- 
duction of  antiseptic  surgery  his  mortality  has  been  reduced  to 
10  per  cent.  He  has  now  performed  the  operation  fifty-six 
times,  and  in  the  last  series  of  thirty  consecutive  cases  since 
1866  only  three  deaths  occurred,  and  of  these  only  one  was 
caused  by  the  operation  (shock).  The  remaining  two  deaths 
supervened  sixty-three  days  and  seven  months  after  the  operation. 
Since  1884  he  applies,  only  one  dressing,  which  is  allowed  to 
remain  from  forty  to  fifty  days,  when  bony  consolidation  was 
found  complete.  He  uses  Neuber's  drains,  and  sutures  the 
wound.  He  advises  the  use  of  a  fixation  dressing  until  bony 
union  is  sufficiently  firm  to  support  the  weight  of  the  body  and 
to  prevent  angular  deformity.  , 

Hitzegrad  ("  Mittheilungen  aus  der  chirurgischen  Klinik 
zu  Kiel,"  B.  iv)  gives  us  the  final  results  after  resection  of  the 
knee-joint  done  at  Kiel  since  the  introduction  of  the  antiseptic 
method  of  treating  wounds  and  the  elastic  tourniquet.  From 
the  results  obtained  in  115  cases  of  complete  or  typical  resection 
of  this  joint,  the  author  comes  to  the  conclusion  that  resection 
should  be  upheld,  when  done  antiseptically  and  with  the  Esmarch 
bandage.  Seventy-three  per  cent,  of  the  severe  cases  were  cured 
in  an  average  of  eighty-five  days,  and  21  per  cent,  of  the  patients 
dismissed  as  more  or  less  completely  cured  had  a  good  use  of 
the  limb  after  five  years  and  a  half.  Of  BoeckePs  58  cases,  55 
were  cured  and  3  died.  Of  47  typical  resections,  44  recovered 
and  3  died.  In  the  remaining  cases  arthrectomy  was  made,  and 
all  of  these  recovered.  Of  the  44  cases  of  typical  resection 
which  recovered  from  the  operation,  3  were  subjected  later  to 


466 


TUBERCULOSIS   OF   THE    BONES    AND    JOINTS. 


amputation,  and  in  4  the  resected  ends  did  not  unite  by  bony 
callus.      In  37,  bony  consolidation  was   obtained.      The  time 

required  to  effect  firm  union 
varied  from  seventeen  to  fifty- 
six  days,  but  in  2  cases  it  re- 
quired two  and  seven  months. 
Zoege-Manteuffel  ("Ueber 
die  Behandlung  fungoser  Knie- 
gelenkentziindung  mittels  Re- 
section. Deiitsrfie  Zeitsclirift 
f.  Chirurgie,  B.  xxix,  p.  1 1 3) 
gives  an  interesting  and  valu- 
able account  of  fifty-five  resec- 
tions of  the  knee-joint,  made 
in  the-clinic  at  Dorpat  during 
the  last  ten  years.  Only  in 
two  of  these  cases  was  the  dis- 
ease limited  to  the  synovial 
membrane;  in  all  the  rest  of 
the  cases  the  disease  had  an 
osseous  origin,  and  the  embolic 
form  appeared  to  predominate. 
On  this  account  many  of  the 
patients  died  later  from  other 
tubercular  affections.  The  re- 
sected ends  were  fastened 
together  by  two  strong  silk 
sutures,  one  on  each  side.  In 
forty-seven  of  these  cases  the 
healing  process  required  from 

FIG.  94.— SHORTENING  OF  T,IMB  AFTER  eight      months     to     two     years. 
COMPLETE  RESECTION  OF  THE  KNEE-JOINT,  IT 

WITH    REMOVAL    OF    BOTH    EPIPHYSIAL  Primary  healing  OI    WOUlld  OC- 
CARTILAGES.    (Pemberton's  case. )  * 

curred  thirty-nine  times.     Six 

deaths,  of  which  one  was  caused  by  carbolic-acid  intoxication, 
four  died  of  general  tuberculosis,  and  one  of  fq,t  embolism, 


TUBERCULOSIS   OF    KNEE-JOINT.  467 

As  to  shortening,  it  is  necessary  to  distinguish  between 
cases  where  the  epiphysial  line  is  preserved  and  where  it  is  not. 
Hoffa  (Arcldv  f.  klin.  Chirurgie,  B.  xxxii,  Heft  4)  observed  that, 
in  the  cases  which  he  reported  from  the  clinic  in  Wiirzburg, 
the  removal  of  both  epiphysial  lirfes  in  children  show  that  at  the 
end  of  ten  years  the  shortening  may  amount  to  twenty-five  and 
oiiohalf  centimetres,  while  in  another  case  it  amounted  in  two 
years  to  ten  centimetres. 

The  shortening,  in  most  of  the  cases,  corresponded  to  the 
time  elapsed.  Where  only  one  epiphysial  line  is  destroyed, 
there  is  still  shortening,  though  less.  Loss  of  the  femoral  line 
showed  seventeen  centimetres  shortening  in  six  years,  and  seven 
centimetres  in  one  and  one-half  years.  Two  cases  of  like  dura- 
tion, affecting  the  tibial  line,  showed  fifteen  and  one-half  and  six 
centimetres,  respectively.  The  cases  in  which  the  epiphysial 
lines  are  preserved  do  not  show  a  gradually  increasing  shorten- 
ing as  strongly  as  when  the  epiphysial  cartilages  are  included  in 
the  resection.  It  amounted,  in  one  of  HofFa's  cases,  at  the  end 
of  six  years,  to  thirteen  and  one-half  conti metres;  in  others,  even 
older  cases,  it  was  much  less,  and  up  to  the  end  of  two  years  it 
never  exceeded  five  centimetres.  To  save  the  epiphysial  line, 
Konig's  rule  is  valuable:  "Saw  off  inside  the  extent  of  the 
cartilage."  After  this,  any  remaining  morbid  deposit  must  be 
scraped  and  chiseled  out.  (Fig.  92.)  Cavities  made  on  the 
surface  of  the  resected  ends  should  be  packed  with  chips  of 
decalcified,  iodoformized  bone,  as  was  done  in  the  following 
case : — 

Tuberculosis  of  Knee-Joint ;  Resection ;  Recovery,  ivith 
Useful  Anlcylosed  Limb. — M.  L.,  a  strong,  healthy-appearing 
female,  26  years  of  age,  witli  no  family  history  of  tuberculosis, 
has  for  the  past  eight  years  suffered  from  knee-joint  trouble. 
One  year  ago  a  layman  undertook  to  effect  a  cure.  This  treat- 
ment was  followed  by  an  acute  synovitis,  which,  after  four 
months'  rest  in  bed,  subsided  so  that  the  patient  was  able  to  get 
around  again.  A  second  attack  occurred  during  the  past 


468  TUBERCULOSIS   OF   THE    BONES    AND    JOINTS.' 

winter,  which  left  the  knee  permanently  enlarged.  Since 
March  she  has  been  walking  on  crutches.  On  admission  to 
the  hospital,  November  5,  1889,  there  was  found  fibrous  anky- 
losis  of  the  knee,  uniform  enlargement  of  the  joint,  which,  to 
the  examining  finger,  felt  firm.  No  glandular  enlargements  in 
the  groin. 

Operation. — Complete  resection  of  the  knee-joint,  patella 
included.  On  section  of  the  tibia,  the  bone  was  found  highly 
osteoporotic,  and  in  the  inner  tuberosity  a  triangular  sequestrum 
surrounded  by  granulation  tissue  and  incased  by  sclerosed  bone. 
Corresponding  to  this,  there  was  present  a  caseous  depot  in 
the  inner  condyle  of  the  femur.  Both  these  were  eliminated, 
and  there  remained  in  the  condyle  a  cavity  the  size  of  a  pigeon's 
egg,  and  in  the  tibia  one  of  half  that  size.  After  complete  ex- 
tirpation of  the  capsule,  thorough  iodoformization  of  the  wound 
and  igni puncture  of  the  tibia,  both  cavities  were  firmly  packed 
with  decalcified  bone-chips  before  bringing  the  resected  ends 
into  apposition.  A  catgut  drain  was  introduced  at  either  angle 
of  the  incision,  which  was  closed  by  deep  sutures  of  catgut  and 
superficial  of  silk.  The  quadriceps  and  patellar  tendons  were 
united  by  a  strong  catgut  suture.  A  copious  antiseptic  dress- 
ing was  applied  and  retained  by  a  plaster-of-Paris  bandage,  in 
which  was  incorporated  a  posterior  iron  splint  extending  from 
the  middle  of  the  thigh  to  the  toes.  The  limb  was  kept  in  an 
elevated  position  for  two  weeks.  The  highest  temperature, 
101.5°  F.,  was  reached  the  evening  of  the  second  day;  the  fol- 
lowing morning  it  was  reduced  to  99°  F.  No  rise  in  tempera- 
ture after  this  date.  At  first  dressing,  on  the  sixteenth  day,  the 
incision  had  completely  healed,  except  at  the  points  of  drainage  ; 
sutures  removed  and  plaster-of-Paris  dressing  re-applied.  Twelve 
days  later  the  dressing  was  removed  and  the  incision  found 
completely  healed.  Examination  at  the  end  of  the  sixth  week 
showed  consolidation  well  advanced,  with  only  three-quarters 
of  an  inch  shortening ;  fixation  dressings  were  dispensed  with 
twelve  weeks  after  operation,  and  the  patient  ordered  to  walk 


TUBERCULOSIS   OF   KNEE-JOINT.  469 

on  crutches.  This  she  refused  to  do  until  two  weeks  later, 
when,  to  her  surprise,  she  could  bear  her  weight  on  the  limb 
without  any  pain  or  inconvenience. 

Arthrectomy. — Arthrectomy  or,  better,  synovectomy  was 
first  performed  for  tuberculosis  of  the  knee-joint.  In  primary 
tuberculosis  of  the  synovial  membrane  this  is  the  operation  par 
excellence.  Anatomically,  the  knee-joint  presents  the  most 
favorable  conditions  for  this  operation  ;  from  a  pathological  point 
it  is  not  often  indicated,  as  primary  synovial  tuberculosis  of  this 
joint  is  much  less  frequent  than  the  osseous  form.  Arthrec- 
tomy and  atypical  resection  combined  are  the  procedures  most 
frequently  applicable,  as  extirpation  of  the  capsule  must  always 
be  combined  with  the  infra-articular  removal  of  osseous  foci 
in  the  condyles  of  the  femur  or  head  of  tibia. 

Volkmann  ("  Die  Arthrectomie  am  Knie."  Centralblatt  f. 
Chirurgie,  No.  9,  1885)  urged  the  substitution  of  extirpation  of 
the  synovial  sac  for  typical  resection,  on  account  of  the  bad 
functional  results — shortening  and  angular  deformity — which  so 
often  follow  the  latter  operation.  He  commences  the  operation 
by  making  a  short  transverse  incision,  and  opening  the  joint  for 
inspection  and  digital  exploration.  If,  upon  such  examination, 
a  complete  arthrectomy  is  deemed  necessary,  he  divides  the  pa- 
tella transversely.  If  the  upper  recess  is  much  affected,  he  ad- 
vises the  formation  of  a  flap  with  base  directed  upward,  in  order 
to  secure  a  more  free  access  to  the  joint.  He  does  not  use 
Esmarch's  constrictor,  as  he  claims  that  in  bloodless  operations  it 
is  not  as  easy  to  distinguish  between  healthy  and  diseased  tissue. 
He  places  great  stress  upon  the  thoroughness  with  which  the 
operation  should  be  done.  Osseous  foci  are  attacked  from  the 
articular  surfaces  of  the  bone.  By  this  operation  joints  are  often 
ankylosed,  but  the  limbs  are  useful  and  not  shortened. 

Mandry  ("  Zur  Frage  der  Arthrectomie  des  Kniegelenks 
bei  Kindern."  Brims'  Beitrdge  znr  klinischen  Chirurgie,  iii, 
Heft  2,  1887)  reports  seven  cases  of  arthrectomy  of  knee-joint 
for  tuberculosis  in  children.  In  six  of  these  cases,  recovery, 


470  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

as  far  as  the  operation-wound  was  concerned,  was  completed 
in  from  four  to  six  weeks,  and  the  function  of  the  joint  was  re- 
stored almost  to  perfection  in  one  of  the  cases;  in  the  rest,  anky- 
losis.  In  one  case  resection  had  to  be  done  as  a  secondary 
operation.  In  four  cases  there  was  no  shortening,  or,  if  it  was 
present  it  was  very  slight,  while  in  the  two  remaining  cases  the 
limb  was  actually  from  one  to  one  and  a  half  centimetres  longer. 
The  author  collected  sixty-three  cases  from  other  sources  in  which 
the  operations  were  done  for  the  removal  of  the  diseased  synovial 
membrane,  and  with  the  utmost  care  to  avoid  removal  of  carti- 
lage and  bone-tissue.  This  made  the  whole  number  of  cases  of 
arthrectomy  of  the  knee-joint,  upon  which  the  author  bases  his 
remarks  on  this  operation,  seventy.  Of  this  number  seven 
died  :  two  of  pulmonary  tuberculosis,  one  each  of  iodoform  intox- 
ication, chloroform  asphyxia,  general  tuberculosis,  tubercular 
peritonitis,  and  tubercular  meningitis.  The  operation  proved  a 
failure  in  nineteen  cases,  as  it  was  followed  by  return  of  the  dis- 
ease, which  was  treated  by  secondary  .resection  six  times,  with 
three  successes  and  three  failures  ;  in  the  latter  amputation  be- 
came necessary;  in  one  case  amputation  was  performed  after 
the  arthrectomy.  In  forty-four  cases  the  result  was  satisfactory. 
In  none  of  these  cases  could  shortening,  to  any  degree,  be  de- 
tected. On  the  other  hand,  in  three,  measurement  of  the  limb 
showed  an  elongation  of  the  limb  from  one  to  one  and  a  half 
centimetres.  The  author  attributes  the  elongation  to  removal 
by  the  operation  of  the  intra-articular  pressure.  A  movable 
joint  was  obtained  in  eight  cases,  ankylosis  thirty-two  times ; 
flail-joint  was  never  observed.  Contracture  of  the  joint  fol- 
lowed in  a  number  of  cases,  which  should  remind  the  surgeon 
again  not  to  remove  immobilization  splints  too  early.  A  movable 
joint  was  obtained  in  several  of  my  cases,  even  when  a  small 
osseous  focus  had  to  be  removed  at  the  same  time,  of  which  the 
following  case  furnishes  a  good  illustration  : — 

Tuberculosis  of  Knee-Joint  ;   Arthrectomy  ;  Recovery,  with 
Good  Motion  of  Joint. — E.  K.,  4|  years  of  age,  child  of  healthy 


TUBERCULOSIS   OF    KNEE-JOINT.  471 

parents,  and  with  no  family  history  of  tuberculosis,  admitted  to 
the  Milwaukee  Hospital  March  10,  1890,  for  an  affection  of 
the  knee-joint,  which  developed  after  an  injury  six  months  ago. 
At  present  the  joint  is  uniformly  enlarged,  painless  and  doughy 
on  palpation.  A  typical  arthrectomy  was  made  on  the  same 
day  and  the  primary  depot  of  infection  found  in  the  intra-con- 
dyloid  notch,  where  limited  sequestration  had  occurred.  When 
this  depot  was  removed  there  remained  a  cavity  the  size  of  a 
hazel-nut,  which  was  packed  with  decalcified  bone-chips.  Re- 
covery was  retarded  by  an  acute  attack  of  catarrhal  icterus, 
which  developed  the  second  day  after  the  operation  and  lasted 
about  a  week.  Some  suppuration  occurred  in  the  superficial 
incision,  which  had  completely  healed  by  the  end  of  the  twelfth 
week.  No  shortening  of  limb.  Motion  in  joint  at  first  limited, 
but  gradually  increased  by  active  and  passive  motion  and 
massage. 

Israel  ("  Zwei  Falle  von  Arthrectomia  synovialis  des  Knie- 
gelenks  mit  erhaltener  Beweglichkeit."  Berl.  klin.  Woclien- 
wlirift,  No.  5,  1889)  reports  two  cases  of  synovial  arthrectomy 
of  the  knee-joint  in  patients,  aged  respectively  39  and  11  years, 
with  excellent  functional  results.  In  the  first  case  the  knee- 
joint  was  opened  by  a  vertical  incision  through  the  patella;  in 
the  second  case  the  interior  of  the  joint  was  made  accessible  by 
sawing  through  the  tuberosity  of  the  tibia  in  an  upward  and 
backward  direction,  after  which  the  wedge-shaped  piece  of  bone 
with  the  tendon  of  the  patella  attached  was  reflected  in  an  up- 
ward direction.  After  extirpation  of  the  diseased  parts,  the 
piece  of  bone,  temporarily  resected,  was  replaced  and  fastened 
with  a  nail.  In  this  case  not  only  the  synovial  membrane,  but 
the  entire  capsule,  crucial  ligament,  and  semilunar  cartilages 
were  removed,  and  yet  the  functional  result  was  excellent,  the 
patient  being  able  to  flex  the  leg  at  a  right  angle  with  the 
thigh.  When  the  synovial  membrane  back  of  the  joint  is  also 
affected  Zesas  (CentraMatt  f.  Chirurgie,  No.  28,  1886)  advises 
that  the  large  popliteal  vessels  should  be  laid  bare  as  far  as  the 


472  .  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

granulation  masses  extend  ;  they  can  then  be  held  aside  until  all 
the  diseased  tissue  has  been  thoroughly  removed.  In  very  bad 
cases  the  vessels  are  to  be  approached  from  the  popliteal  space, 
and  then  drawn  back  out  of  the  way  until  the  capsule  has  been 
removed.  In  several  cases  of  arthrectomy  of  the  knee-joint  in 
young  adults,  where  I  had  to  remove  the  entire  capsule,  the 
patients  recovered  with  limited  motion  of  the  joint. 


CHAPTER   XXXVII. 

TUBERCULOSIS  OF  ANKLE-JOINT  AND  TARSUS. 

TUBERCULOSIS  of  the  ankle-joint  and  tarsus  have  much  in 
common,  as  the  disease  is  very  prone  to  extend  from  the  for- 
mer to  the  latter,  and  vice  versa,  while  the  etiological  factors  in 
the  causation  of  the  disease  in  both  localities  are  identical. 

Primary  Location  of  Disease. — Tuberculosis  of  the  foot 
occurs  most  frequently  in  the  parts  which  transmit  the  weight 
of  the  body  to  the  ground,  namely,  the  ankle-joint,  os  calcis, 
head  of  astragalus,  the  tarsal  bones,  and  the  proximate  end  of 
the  first  metatarsal  bone. 


FIG.  95.— SAGITTAL  SECTION  OF  Os  CALCIS.    Natural  size.    (Krause.) 

a,  in  the  middle  of  the  bone  a  large  cheesy  sequestrum ;  b,  perforation  toward  surface  in  the  form 
of  a  cloaca. 

Miinch  states  that  in  28  cases,  where  the  ankle-joint  alone 
was  affected,  the  disease  was  primarily  synovia!  in  23,  the  lower 
end  of  the  tibia  in  1,  and  the  astragalus  in  4.  Erasmus,  on  the 
other  hand,  found  in  11  cases  that  only  2  were  primarily  syno- 
vial,  in  3  sequestra  were  present,  and  in  6  there  were  caseous 
deposits  in  one  of  the  articulating  bones. 

Cheyne  is  of  the  opinion  that  in  the  ankle-joint  primary 
synovial  disease  is  much  more  common  than  primary  osseous 
disease,  and  that  the  osseous  form  begins  most  frequently  in  the 
astragalus,  and  next  in  frequency  comes  the  upper  part  of  the 

(473) 


474 


TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 


malleoli.  Czerny  found,  in  fifty-two  cases,  that  the  astragalus 
was  affected  fifteen  times,  the  os  calcis  thirteen,  the  cuboid 
sixteen,  the  scaphoid  and  cuneiform  eight. 

Treatment  by  iodoform  injections  in  tuberculosis  of  the 
ankle  deserves  a  faithful  trial,  although  the  results  are  not  as 
favorable  as  in  the  treatment  of  the  same  affections  of  the  knee- 
joint.  As  extension  of  this  joint  is  not  applicable,  the  remain- 
ing conservative  treatment 
must  consist  in  immobiliza- 
tion, which  is  done  most  effi- 
ciently by  applying  a  plaster- 
of-Paris  boot  reaching  from 
the  toes  to  the  knee-joint, 


FIG.  96.— TUBERCULAR  OSTEOMYELITIS 
OF  ASTRAGALUS. 


FIG.  97. — FUNGOUS  SYNOVITIS  OF  ANKLE- 
JOINT. 


interposing  a  thick  layer  of  aseptic  hygroscopic  cotton  to  prevent 
decubitis  over  bony  prominences. 

RESECTION   OF   ANKLE-JOINT. 

History  of  Operation. — The  technique  of  resection  of  the 
ankle-joint  has  undergone  many  radical  changes  since  this 
operation  was  first  practiced.  Resection  of  the  ankle-joint  for 
compound  fracture  has  been  practiced  since  1792  by  Rumsey, 
Read,  Weber,  and  Sedillot,  but  the  first  operation  for  disease 
of  this  joint  was  made  by  Moreau  in  1792.  Champion  per- 


TUBERCULOSIS   OF    ANKLE-JOINT   AND    TARSUS.  475 

formed  the  operation  in  1813.  Roux  in  1832,  Jiiger  in  1833, 
Textor  in  1844,  Heyfelder  in  1845,  Wakley  in  1847,  and 
Hussey  in  1858. 

Incision.  —  Chassaignac  recommended  a  single,  straight, 
external  incision.  Bonrgerie  made  two  incisions,  one  on  each 
side,  three  to  four  inches  in  length,  parallel  with  the  tibia  and 
fibula,  each  terminating  a  little  below  the  respective  malleolus. 
Moreau  advises  two  incisions,  three  inches  or  more  hi  length, 
along  the.  posterior  edge  of  the  tibia  and  fibula,  from  their  in- 
ferior extremities  upward,  and  then  two  transverse  cuts  from 
the  lower  ends  of  these,  in  a  direction  forward,  as  far  as  the 
tendon  of  the  tibialis  anticus  on  the  tibial,  and  that  of  the  pero- 
neus  tertius  on  the  fibular  side.  The  flaps  thus  formed  having 
been  raised,  the  bones  of  the  leg  are  exposed  and  divided,  by 
means  of  the  saw  or  pliers,  as  high  as  may  seem  necessary,  after 
which  the  separation  of  the  ligamentous  connection  is  easily 
effected.  Jager  made  the  transverse  cuts  a  little  longer,  and,  if 
necessary,  on  each  side  of  the  long  cut.  Velpeau  and  Gue- 
pratte  gave  to  the  lower  end  of  the  long  incisions  a  semilunar 
shape  by  following  the  margins  of  the  malleoli  forward. 

J.  F.  Heyfelder  and  Sedillot  opened  the  joint  freely  in  front 
by  a  transverse  incision,  which  also  severed  the  extensor  ten- 
dons, while  Hussey  made  a  semilunar  flap  on  the  same  side  with 
the  base  directed  upward. 

O.  Heyfelder  does  not  believe  that  it  is  necessary  to  divide 
the  extensor  tendons,  which  he  claims  can  be  held  out  of  place 
by  retractors  during  the  removal  of  the  joint. 

A  posterior  transverse  incision  with  division  of  the  tendo 
Achillis  was  practiced  by  Wakley  and  Textor.  Pelikan' divided 
the  tibia  and  astragalus  obliquely,  so  that  the  sawn  surfaces 
should  overlap  each  other. 

Modern  Operation. — About  thirty-five  kinds  of  incisions 
have  been  devised  by  different  surgeons  for  resection  of  the 
ankle-joint,  which  show  'conclusively  that  none  of  them  fully 
answer  the  purpose.  It  is  impossible  to  devise  any  one  incision 


476  TUBERCULOSIS   OF   THE   BONES    AND   JOINTS. 

that  will  be  applicable  to  all  cases.  Special  indications  call  for 
different  incisions.  The  incisions  which  will  be  described  in  the 
next  section  of  this  chapter  will  be  found  useful  in  different 
cases.  The  existence  of  fistulous  opening's  will  often  determine 
the  kind  of  incision  which  it  is  necessary  to  make  to  gain  access 
to  the  joint,  and  enable  the  surgeon  to  remove  all  of  the  infected 
tissues  without  injuring  important  para-articular  structures. 

Textor  (Osann,  "Ueber  die  Resection  des  Fussgelenks." 


rn.ext.dig. 


--  m.  ext.  hal. 


FIG.  98.— HUETER'S  ANTERIOR  INCISION. 

m.  ext.,  external  malleolus;  /«.  int.,  internal  malleolus:  m.  lib.  a,  anterior  tibial  muscle;  m.  ext. 
hal.,  extensor  muscle  of  toe:  a.  tib.  a.,  anterior  tibial  artery  ;  «.  per.,  peroneal  nerve  :  m.  rxt.  dig.,  ex- 
tensor muscles  of  toes. 

Wiirzburg,  1853)  makes  a  posterior  transverse  incision  from  the 
middle  of  the  posterior  border  of  one  malleolus  to  a  correspond- 
ing point  on  the  opposite  side,  which  divides  also  the  tendo 
Achillis.  Before  the  tendon  is  divided  the  upper  portion  is  fixed 
in  a  loop,  so  that  it  can  be  readily  found  when  wanted.  The 
deep  fascia  is  carefully  divided  upon  a  grooved  director  in  order 
to  avoid  injury  to  the  important  vessels  and  nerves.  The  joint 
is  then  opened  by  a  longitudinal  incision  parallel  to  the  middle 


TUBERCULOSIS    OF    ANKLE-JOINT    AND    TARSUS.  477 

of  the  tendo  Achillis.  If  necessary,  the  lateral  ligaments  are 
divided  with  a  blunt-pointed  bistoury,  and  the  diseased  bones 
and  capsule  removed  with  chisel,  sharp  spoon,  and  scissors. 
The  tendo  Achillis  is  separately  sutured  before  the  external 
wound  is  united. 

Hueter  ("Ueber  Resection  des  Fussgelenks  mit  vorderem 
Querschnitt"  Arcliiv  f.  klin.  Chinirgie,  B.  xxvi,  S.  812)  ob- 
served so  many  relapses  in  his  operations  on  the  ankle-joint  for 
tubercular  affections  by  Langenbeck's  method  that  he  devised 
a  more  direct  route  into  the  joint. 

He  makes  an  anterior  transverse  incision  by  cutting  from 
the  posterior  border  of  the  internal  malleolus  around  the  tip  and 
across  the  ankle  in  front,  to  a  point  on  the  posterior  margin  of 
the  external  malleolus  corresponding  with  a  point  opposite, 
where  the  incision  was  commenced  on  the  inner  side.  The 
superficial  peroneal  is  divided  by  the  incision.  After  dividing 
carefully  the  deep  fascia,  the  operator  looks  for  the  tendon  of 
the  anterior  tibial  muscle,  which  is  transfixed  with  a  strong  cat- 
gut thread,  to  which  the  needle  remains  attached.  The  tendon 
of  the  extensor  pollicis  is  dealt  with  in  the  same  manner.  .By 
making  traction  on  both  catgut  threads  the  tendons  are  separated 
sufficiently  to  find  the  anterior  tibial  artery,  which  is  divided 
between  two  ligatures.  The  veins  are  similarly  ligated  and 
divided.  The  nervus  peroneus  profundus  is  divided  as  well  as 
the  tendons  of  the  extensor  communis,  which  is  also  fixed  with 
a  ligature  and  cut  below.  The  anterior  wall  of  the  capsule  of 
the  joint  is  now  divided  transversely,  and,  while  the  foot  is 
strongly  flexed  toward  plantar  surface,  the  talo-fibular,  calcano- 
fibular  on  the  outer  side,  and  the  deltoid  ligament  on  inner  side 
are  put  on  the  stretch  and  divided.  The  necessary  removal  of 
diseased  tissue,  synovial  and  osseous,  can  now  be  done  with 
ease.  After  the  resection  the  divided  muscles  and  nerve  are 
sutured.  Two  transverse  drains  are  inserted  and  the  external 
wound  closed. 

Konig's  ("Ueber  die  Operationsmethode  des  Verfassers  bei 


478 


TUBERCULOSIS    OF    THE    BONES    AND    JOINTS. 


Tuberculose  des  Tibio-Tarsal  und  des  Talo-Tarsalgelenkes." 
Archiv  f.  Min.  Chirurgie,  Bd.  xxxii)  operation  is  based  upon 
the  apparent  necessity  of  exposing  freely  the  synovial  sac  upon 
the  anterior  aspect  of  the  joint. 

Two  incisions  are  made  over  the  anterior  aspect  of  the  joint 
which  include  the  anterior  portion  of  the  capsule.  The  princi- 
pal incision,  the  inner,  is  made  over  the  anterior  aspect  of  the 
tibia,  commencing  about  three  centimetres  above  the  joint,  and 
is  made  to  curve  along  the  anterior  bor- 
der of  the  internal  malleolus,  and  as  soon 
as  the  joint  is  reached  the  incision  is  made 
into  the  joint,  down  to  the  neck  of  the 
astragalus,  and  is  terminated  at  the  junc- 
tion of  the  astragalus  with  the  scaphoid. 
The  incision  opposite  to  this  one  is  made 
along  the  anterior  border  of  the  fibula, 
into  the  joint,  and  terminating  again  at 
the  scaphoid.  The  bridge  of  soft  tissues 
over  the  ankle-joint  lying  between  these 
incisions  is  carefully  separated  with  for- 
ceps, elevator,  and  knife,  from  the  anterior 
capsule  of  the  joint,  sufficiently  far  so  that 
it  can  be  lifted  away  from  the  joint  far 
enough  to  enable  the  free  removal  of  the 
capsule.  If  resection  becomes  necessary, 
this  operation  is  commenced  by  cutting 
with  a  chisel  through  the  base  of  the  malleoli  in  such  a  manner 
that  the  external  cortical  layer  is  not  cut,  but  is  fractured,  and 
the  malleoli  are  turned  outward.  Injury  to  tendons  can  always 
be  avoided  by  observing  ordinary  care. 

After  elevating  the  flap  a  wide  chisel  is  used  in  cutting  off 
the  lower  end  of  the  tibia.  The  removal  of  the  disk  of  bone  is 
sometimes  quite  difficult,  but  can  always  be  accomplished. 
The  upper  surface  of  the  astragalus  is  now  well  exposed. 
Unless  special  indications  are  present,  only  the  upper  surface 


FIG.  99.— KONIG'S  INCISIONS. 


TUBERCULOSIS   OF    ANKLE-JOINT   AND   TARSUS.  479 

is  removed  with  the  chisel.  If  the  whole  bone  is  affected,  or  if 
disease  has  extended  to  joint  between  it  and  calcaneus,  the  whole 
bone  is  extirpated.  The  synovial  membrane  must  be  thoroughly 
extirpated  with  dissecting  forceps  and  scissors.  The  most  diffi- 
cult part  to  remove  is  the  posterior  duplicature  of  the  capsule, 
extending  from  the  posterior  margin  of  the  tibia  to  the  talus; 
this  part  of  the  operation  is  greatly  facilitated  by  extension  and 
flexion  of  the  foot.  After  disinfection  and  iodoformization  of 
the  joint  a  drain  is  inserted  into  each  lower  angle  of  the  wounds, 
and  the  balance  is  sutured.  The  foot  maintains  now  its  own 
position,  especially  if  what  remain  of  the  malleoli  is  pressed 
toward  the  joint.  A  copious  .Lister  dressing  is  applied,  and  the 
limb  placed  in  an  elevated  position  for  at  least  twelve  hours. 
After  the  wounds  have  healed,  no  apparatus  is  required  to 
prevent  deformity,  as  the  foot  is  kept  in  normal  position 
without  any  mechanical  support. 

Ebert  ("  Ueber  Resection  des  Talo-cruralgelenkes  mit  dor- 
salem  Lappenschnitt."  Dissertation.  Greifswald,  1889)  de- 
scribes Helferich's  new  operation  for  resection  of  the  ankle- 
joint  and  reports  three  cases  operated  upon  by  this  method. 
The  ankle-joint  is  exposed  anteriorly  after  the  reflection  of  a 
short  dorsal  flap.  A  transverse  incision  is  made  across  the  dor- 
sum  of  the  foot  down  to  the  bone  at  a  point  or  a  little  above 
Lisfranc's  joint,  and  from  the  ends  of  this  incision  another  in- 
cision is  made  on  each  side  of  the  malleoli.  The  flap,  including 
fascia,  tendons,  nerves,  and  vessels,  is  detached  from  the  bones 
and  reflected  upward ;  while  the  foot  is  forcibly  extended  the 
malleoli  on  each  side  are  cleared  and  the  lower  end  of  the  tibia 
and  fibula  resected.  After  this,  as  much  of  the  tarsal  bones  as 
may  appear  necessary  is  removed,  and,  if  required,  a  portion  of 
the  ends  of  the  metatarsal  bones.  If  ankylosis  appear  desirable, 
bone  sutures  are  advised.  Tendons  are  not  sutured.  The 
healing  and  functional  result  in  the  three  cases  were  satisfactory. 

Schmidt  ("  Vorderer  und  hinterer  Langschnitt  zur  Aus- 
fiihrung  der  Arthrectomia  synovialis  am  Talocruralgelenk." 


480  TUBERCULOSIS    OF    THE    BONES    AND   JOINTS. 

Centralblatt  f.  CJiirurgie,  No.  2,  1889),  of  Cuxhaven,  reason- 
ing from  the  fact  that  the  capsule  of  the  ankle-joint  is  much 
longer  in  front  and  hehind  the  joint  than  on  the  sides,  recom- 
mends to  expose  this  joint  in  making  arthrectomy  by  an  incision 
in  front  and  behind.  He  makes  the  posterior  incision  about  six 
centimetres  in  length,  close  to  and  in  the  course  of  the  tendo 
Achillis  down  to  the  prominence  of  the  os  calcis,  dividing  the 
skin,  fascia,  and  subfasciul  fat.  The  margins  of  the  wound  are 
now  retracted,  when  the  bulging  capsule  comes  in  sight,  resem- 
bling somewhat  in  appearance  a  lipomatons,  hernial  sac. 
After  incision  the  capsule  prolapses  more,  and  is  easily  extir- 
pated with  forceps  and  scissors.  The  joint  is  now  freely  opened 
and  can  be  explored  with  the  finger.  The  anterior  incision  is 
made  in  the  same  manner  as  has  been  advised  by  Vogt,  vertical, 
and  at  a  point  about  the  middle  between  the  malleoli,  which  ex- 
poses the  important  vessels  and  nerves  in  this  region.  The  ten- 
dons of  the  extensor  pollicis  are  drawn  toward  the  inner  side 
with  blunt  hooks.  The  anterior  recess  of  the  joint  is  now 
reached  and  incised,  when  the  capsule  is  thoroughly  extirpated, 
after  which  the  interior  of  the  joint  can  be  easily  inspected  and 
diseased  tissue  removed.  Should  it  become  necessary  to  remove 
osseous  foci,  Kocher's  lateral  incision  can  be  added,  which  would 
then  afford  an  abundance  of  room. 

According  to  Paulsen  ("  Ueber  Arthrectomie  des  Fuss- 
gelenkes  mit  temporarer  extirpation  des  Talus."  Centralblatt 
f.  Chirurgie,  No.  31,  1889),  it  is  always  necessary  to  remove  the 
talus  in  making  an  arthrectomy  of  the  ankle-joint,  otherwise  it 
is  impossible  to  inspect  the  articular  surface  of  the  tibia  and  the 
space  between  the  articular  extremity  of  this  bone  and  the 
fibula.  It  is  also  a  common  condition  to  find,  during  the  opera- 
tion, that  the  disease  has  extended  to  the  talo-tarsal  joint. 
Iverson  opens  the  ankle-joint  by  a  curved  anterior  incision,  and 
removes  the  astragalus.  Functional  results  good.  As  the 
astragalus  in  several  cases  showed  no  signs  of  disease,  Paulsen 
suggests  that  this  bone  might  perhaps  be  replaced  after  the 


TUBERCULOSIS   OF    ANKLE-JOINT    AND    TARSUS.  481 

completion  of  the  arthrectomy.  This  was  done  successfully  in  a 
child  7  years  of  age. 

Busch  ("  Eine  neue  Methode  zur  Resection  oder  dem 
Evidement  des  Fussgelenkes  bei  fungoser  Entzimdung."  Cen- 
tralblatt  f.  Cldrurgie,  No.  41,  1882)  has  devised  an  incision  by 
which  the  ankle-joint  is  freely  exposed  by  an  osteoplastic  resec- 
tion of  the  os  calcis.  He  carries  the  incision  from  the  external 
surface  of  one  malleolus  to  the  other  by  cutting  down  and 
across  as  far  as  the  sole  of  the  foot,  and  in  front  of  the  tuber- 
osity  of  the  os  calcis,  then  curving  slightly  backward  and  upward 
to  the  external  malleolus  to  a  point  opposite  to  where  the  incis- 
ion was  started.  The  tendons,  vessels,  and  nerves  are  carefully 
avoided,  but  as  soon  as  the  os  calcis  is  reached  the  cut  is  made 
to  the  bone.  The  tendons,  vessels,  and  nerves  in  the  groove 
behind  the  malleolus  on  each  side  are  carefully  lifted  out  with 
an  elevator,  and  kept  out  of  the  way  with  retractors,  while 
the  os  calcis  is  sawn  from  the  anterior  border  of  the  tuberosity 
in  an  oblique  direction  upward  and  backward,  toward  the  pos- 
terior articular  surface  of  the  astragalus.  After  dividing  the 
posterior  wall  of  the  capsule,  the  ankle  is  freely  opened.  If 
necessary,  the  astragalus  can  be  removed,  and  osseous  foci  in 
the  lower  end  of  the  tibia  and  fibula  can  now  be  removed. 
If  the  os  calcis  is  healthy,  the  bone  is  replaced  after  complete 
removal  of  the  synovial  membrane,  and  united  with  two  metallic 
sutures. 

Schmid-Monnard  ("Ueber  Pathologic  und  Prognose  der 
Gelenktuberculose,  insbesondere  des  Fusses."  Kiel,  1888)  re- 
ports nine  cases  of  resection  of  the  ankle-joint  for  tuberculosis 
from  Neuber's  clinic.  One  patient  succumbed  to  intestinal 
tuberculosis  twenty-two  months  after  the  operation ;  the  remain' 
ing  number  recovered,  and  remained  well  two  and  a  half  to 
three  and  three-quarter  years  after  operation, — the  time  the  re- 
port was  made.  The  functional  result  in  six  was  excellent,  and 
in  two  fair.  He  has  collected  ninety-two  cases  of  resection  of 
the  ankle-joint  for  tuberculosis,  of  which  number  70.6  per  cent. 

31 


482  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

healed  without  recurrence  to  29.4  per  cent,  in  which  the  result 
was  not  favorable.  Consequently,  about  25  per  cent,  of  all  re- 
sections of  this  joint  remain  unhealed  locally,  in  spite  of  subse- 
quent amputation,  which,  at  times,  had  to  be  resorted  to  after 
resection  proved  a  failure.  He  recommends  Hueter's  transverse 
dorsal  incision.  The  transverse  incision  (Bardenheuer)  through 
the  extensor  tendons  affords  ample  space  in  the  operative  treat- 
ment of  the  deeper  affections  of  the  anterior  tarsal  region,  but 
the  final  result  is  often  unsatisfactory,  on  account  of  adhesions 
of  the  severed  tendons  to  the  skin  and  cicatrix,  and,  conse- 
quently, impaired  motion  of  the  toes.  To  prevent  this,  Studs- 
gaard  (Centralblatt  f.  Chirurgie,  No.  43,  1890)  recommends  a 
longitudinal  incision.  He  splits  the  foot  from  before  backward 
between  second  and  third  toes,  cutting  through  the  ligamenta 
tarso-metatarsea  and  opening  the  capsule  between  the  middle 
and  external  cuneiform  bones.  First  and  second  toes,  with  their 
cuneiform  bones,  may  now  be  moved  inward;  third,  fourth,  and 
fifth  toes,  with  the  external  cuneiform  and  the  cuboid  bones, 
outward,  and  the  tarsus  widely  opened.  It  is  now  very  easy  to 
remove  the  diseased  bones  and  soft  tissues,  and  then  suture  the 
wound  along  the  dorsum  and  planta  of  the  foot,  leaving  a  drain 
through  the  foot  in  the  posterior  angle.  The  only  tendon 
severed  is  that  of  the  peroneus  longus,  which  crosses  the  in- 
cision in  the  planta  on  its  way  to  the  cuneiform  bones  and  the 
bases  of  first  and  second  metatarsal  bones.  No  large  arteries  or 
nerves  are  severed.  The  author  reports  a  case  in  which  the 
result  was  very  satisfactory. 

Albanese  ("Sulla  resezione  dell  articolazione  tibio-tarsica." 
Dissertation,  1869)  makes  an  outer  incision  slightly  curved, 
nine  to  ten  centimetres  in  length,  extending  from  a  point  seven 
centimetres  above  the  tip  of  the  external  malleolus  to  the  cuboid 
bone,  and  divides  in  one  stroke  of  the  knife  all  the  soft  tissues. 
The  dislocation  of  the  joint  is  easily  affected  after  division  of 
the  external  lateral  and  interosseous  ligaments.  He  reports 
three  cases  operated  on  by  this  method,  two  of  which  proved 


TUBERCULOSIS    OF    ANKLE-JOINT    AND    TARSUS.  483 

successful ;  in  the  third,  Syme's  amputation  had  to  be  performed 
one  year  later,  for  return  of  the  disease. 

Lauenstein  ("Ein  einfacher  Weg,  das  Fussgelenk  freizu- 
legen."  Arch.  f.  klin*  Chirurgie,  B.  xl,  Heft  4)  makes  the  state- 
ment that  not  less  than  thirty-three  methods  of  resecting  this 
joint  have  been  devised.  His  method  consists  in  doing  as  little 
violence  to  the  important  soft  tissues  surrounding  the  joint  as 
possible,  and  yet  securing  free  access  to  the  joint 

Fig.  100  shows  the  location  and  extent  of  the  external 


FIG.  100. — LAUENSTEIN'S  OPERATION.    EXTERNAL,  INCISION. 

incision.  The  soft  tissues  on  each  side  of  the  lower  end  of  the 
fibula  are  carefully  separated,  and  after  division  of  the  ligament 
on  the  outside,  in  front  and  behind  the  joint,  the  talus  is  dislo- 
cated by  placing  the  foot  in  equinus  position  and  rotating  it 
inward.  The  joint  is  now  freely  exposed,  as  may  be  seen  from 
Fig.  101,  and,  while  the  soft  tissues  are  kept  out  of  the  way  by 
blunt  retractors,  the  arthrectomy  or  resection  can  be  readily 
made. 

The  functional  result  after  a  successful  resection  of  the 
ankle-joint  is  usually  satisfactory,  and  often  almost  perfect.    The 


484 


TUBERCULOSIS    OF    THE    BONES    AND    JOINTS. 


following  case,  that  came  under  my  observation,  is  here  inserted 
to  illustrate  this  point: — 

Tuberculosis  of  Ankle-Joint  ;  Resection  ;  Almost  Perfect 
Functional  Result. — W.  C.,  male,  19  years  of  age,  was  admitted 
into  the  Milwaukee  Hospital,  January  21,  1890,  with  the  follow- 
ing history  :  Father  died  of  asthma,  and  two  sisters  of  phthisis 
pulmonalis.  At  the  age  of  7  the  patient  had  measles,  followed 
by  sore  eyes  for  a  period  of  three  years;  as  the  eyes  improved, 
trouble  developed  in  the  left  ankle,  which  compelled  him  to  use 
crutches  for  three  years  more.  He  continued  well  until  about 


FIG.  101.— LAUENSTEIN'S  OPERATION.    DEEP  DISSECTION. 

four  months  ago.  when  the  same  ankle  began  to  swell ;  no  pain 
at  any  time  except  when  stepping  hard  on  the  heel. 

Present  Condition. — Patient  very  anaemic,  ankle  ankylosed 
and  enlarged,  no  fluctuation,  swelling  most  marked  behind  the 
external  malleolus,  thickening  of  the  lower  end  of  the  tibia. 

Operation. — Chisel  resection  of  the  malleolus  externus  and 
articular  surface  of  the  tibia,  and  complete  removal  of  the  as- 
tragalus through  a  linear  incision  behind  the  external  malleolus. 
The  primary  depots  were  found  to  be  in  the  tibia,  from  which 
the  disease  had  extended  to  the  articulation  and  the  astragalus. 

o 

After  removal  of  these  depots  two  cavities  remained,  one  the 


TUBERCULOSIS    OF    ANKLE-JOINT    AND    TARSUS.  485 

size  of  a  marble  and  the  other  half  that  size.  These  were  filled 
with  decalcified  hone-chips  and  the  bones  brought  into  appo- 
sition ;  incision  closed ;  foot  placed  on  a  rectangular  splint  and 
retained  by  plaster-of- Paris  splint.  On  the  third  day  a  change 
of  dressing  was  necessitated  because  of  saturation  with  bloody 
serum.  Seventeen  days  subsequently  the  sutures  were  removed  ; 
union  complete,  except  at  the  points  of  drainage.  With  the 
exception  of  the  formation  of  a  small  connective-tissue  abscess 
on  the  inner  side  of  the  tendo  Achillis,  recovery  was  uninter- 
rupted ;  patient  walked  on  crutches  at  the  end  of  the  second 
month,  and  left  the  hospital  two  weeks  later  greatly  improved 
in  general  health,  with  good  motion  of  the  ankle-joint.  The 
ultimate  functional  result  in  this  case  was  almost  perfect. 

Arthrectomy. — The  anatomical  structure  and  the  surround- 
ings of  this  joint  are  not  well  adapted  for  arthrectomy  without 
removal  of  some  of  the  bony  structures  which  enter  into  the 
formation  of  the  joint.  It  has,  therefore,  been  found  difficult  to 
devise  incisions  which  would  enable  the  surgeon  to  extirpate 
the  soft  structures  of  the  joint  without  interfering  with  the 
articular  ends.  One  of  the  best  incisions,  so  far  devised,  for 
reaching  every  portion  of  the  ankle-joint  without  injury  to  im- 
portant soft  parts  and  without  implicating  the  bony  structures, 
is  the  one  described  by  Kocher  (Archiv  f.  Idinische  CJdrurgie, 
E.  xxxiv,  Heft  2)  in  1883.  The  foot  being  held  at  its  normal 
right  angle,  an  incision  is  made  from  the  tendo  Achillis,  with  a 
slight  downward  curve  over  the  tip  of  the  external  malleolus  to 
the  extensor  tendons.  After  dividing  skin  and  fascia,  the 
peroneal  tendons  are  exposed,  tied  with  two  loops,  and  divided 
between.  This  last  cut  also  opens  the  external  portion  of  the 
ankle-joint.  The  ligament  attachments  to  talus  and  calcaneus 
are  then  severed,  and  the  joint-capsule  dissected  from  the  ante- 
rior and  posterior  side  of  the  tibial  joint-surface  as  far  toward  the 
internal  malleolus  as  possible.  The  foot  can  now  be  readily  dis- 
located inward,  care  being  taken  not  to  break  off  the  tip  of  the 
internal  malleolus.  In  this  position  of  the  foot  the  whole  of 


486         ,        TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

the  interior  of  the  joint  is  freely  exposed.  After  excision  of  the 
diseased  parts  the  foot  is  again  brought  into  its  normal  position, 
and  the  tendons  are  sutured.  The  wound  is  now  closed  and 
dressed  in  the  usual  manner.  This  method  closely  resembles 
that  of  Reverdin,  except  that  the  latter  also  divides  the  tendo 
Achillis  and  does  not  suture  the  peroneal  tendons.  The  results 
in  five  cases  of  tuberculosis  of  the  ankle-joint,  operated,  on  by 
this  method,  were  excellent. 

Reverdin's  (French  Surgical  Congress,  1885)  method  of 
incising  the  ankle-joint  for  the  removal  of  tubercular  products 
permits  the  operator  to  decide,  when  he  has  opened  the  ankle- 
joint,  to  what  extent  he  will  remove  the  parts.  His  incision  ex- 
tends from  the  edge  of  the  tendo  Achillis  forward,  and  almost 
horizontally  beneath  the  external  malleolus,  as  far  as  the  inser- 
tion of  the  peronei.  He  has  devised  a  light  form  of  forceps  with 
which  to  seize  and  extract  the  astragalus.  When  that  bone  has 
been  removed  he  examines  carefully  the  parts  left,  and  if  he 
finds  it  necessary,  for  the  complete  examination  of  the  joint  or 
removal  of  the  disease,  he  divides  the  tendo  Achillis.  Or,  on 
the  other  hand,  he  can  now  change  the  operation  into  an 
amputation  of  the  foot  with  an  internal  plantar  flap.  He  has 
found  no  inconvenience  to  follow  division  of  the  tendo  Achillis. 

Girard  ("  Ueber  die  Arthrectomie  des  Fussgelenkes." 
Correspondenzblatt  f.  Sctiweizer  Aerzte,  p.  19,  1887)  claims  that 
incision  of  the  capsule  in  operations  upon  joints  leaves  the  joint 
in  a  weakened,  imperfect  condition,  and  he  has,  therefore,  de- 
vised an  osteoplastic  operation  in  gaining  access  to  the  ankle- 
joint. 

The  limb  resting  on  the  internal  surface,  a  horizontal  in- 
cision is  made  over  the  outer  aspect  of  the  ankle-joint,  at  a  point 
corresponding  with  the  line  of  the  joint,  beginning  at  the  outer 
margin  of  the  tendo  Achillis  and  terminating  at  the  extensor 
muscles  of  the  foot,  dividing  all  the  tissues  down  to  the  bone,  in- 
cluding the  tendons  of  the  peroneal  muscles.  The  external 
malleolus  is  now  cut  through  with  knife  or  chisel,  at  a  point 


TUBERCULOSIS   OF   ANKLE-JOINT   AND   TARSUS. 


487 


corresponding  with  the  horizontal  fissure  of  the  joint.  If  the 
joint  has  been  rendered  loose  by  the  disease,  it  is  now  easy  to 
turn  the  foot  inward  sufficiently  to  expose  fully  its  interior ;  if 
this  is  not  the  case  a  vertical  incision  is  made  through  the  soft 
tissues,  .along  the  anterior  border  of  the  external  malleolus. 
After  extirpation  of  the  capsule  the  divided  tendons  are  sutured 
and  the  external  malleolus  is  carefully  replaced,  and  retention 
secured  by  suturing  with  catgut.  The  joint  is  completely  closed 
by  introducing  a  suture  in  front  and  behind  the  malleolus. 

Bruns  (Munch.  Med.  Wochenschrift,  No.  24,  1891)  has  re- 
cently described  a  new  method  of  performing  arthrectomy  of 


FIG.  102.— GIRARD'S  METHOD  OF  EXCISION  OF  THE  ANKLE-JOINT. 

the  ankle-joint.  This  is  the  latest  addition  of  about  thirty-five 
methods  that  have  been  devised  by  different  surgeons  for  the 
operative  removal  of  diseased  tissue  from  this  joint.  This  opera- 
tion is  intended  to  furnish  the  best  access  to  the  joint  not  only 
for  the  purpose  of  removing  osseous  foci,  but  also  the  diseased 
soft  structures  of  the  joint.  It  is  a  modification  of  Konig's 
operation,  which  consists  in  two  long  anterior  incisions.  It  ex- 
poses the  anterior  synovial  sac,  and  permits  of  removal  of  this 
membrane  and  of  the  articular  ends  of  tibia  and  astragalus  ;  but 
the  posterior  portion  of  the  joint  remains  inaccessible,  and  the 
soft  structures  in  this  part  of  the  joint  cannot  be  extirpated 
unless  the  entire  astragalus  is  removed.  To  the  two  anterior 


488  TUBERCULOSIS   OF   THE   BONES   AND   JOINTS. 

incisions  Bruns  adds  two  posterior,  carrying  one  along  the  inner, 
the  other  along  the  outer,  edge  of  the  tendo  Achillis.  The  an- 
terior incisions  are  commenced  about  four  centimetres  above  the 
joint,  and  carried  downward  in  front  of  the  corresponding  mal- 
leolus  as  far  as  the  medio-tarsal  joint.  The  intervening  portion 
of  soft  structures  having  been  separated  from  the  bones,  the  an- 
terior synovial  sac  is  dissected  away.  The  interior  of  the  joint 
is  now  exposed,  and  the  ends  of  the  bones  can  be  dealt  with  ac- 
cording to  the  primary  origin  and  extent  of  the  disease.  If  the 
whole  of  the  joint  is  diseased,  the  articular  ends,  including  both 
malleoli,  are  removed,  and  one  or  two  posterior  incisions  made 
so  as  to  expose  and  enable  extirpation  of  the  rest  of  the  syno- 
vial sac.  If  only  one  posterior  incision  is  necessary,  this  should 
be  carried  along  the  outer  side  of  the  tendo  Achillis.  After  the 
removal  of  the  diseased  parts  of  the  joint  the  anterior  incisions 
are  sutured,  whilst  the  posterior  are  left  open  for  drainage. 
Bruns  has  made  this  operation  fourteen  times  with  very  good 
immediate  and  remote  results,  and  recommends  it  strongly  as 
the  one  which  affords  freest  exposure  of  the  diseased  joint,  and 
at  the  same  time  makes  it  unnecessary  to  injure  important 
parts. 

Results. — The  functional  results  of  a'rth  recto  my  and  resec- 
tion of  ankle-joint,  when  the  operation  is  limited  to  removal  of 
diseased  tissue,  are  usually  satisfactory. 

Erasmus  ("  Die  Arthrectomien  des  Fussgelenkes  nach 
Konig."  Deutsche  Med.  Wochenschrift,  p.  349,  1885)  reports 
eleven  cases  of  arthrectomy  of  the  ankle-joint  made  by  Biedel 
in  three  years.  The  patients  were  children  from  1  to  10  years 
of  age,  and  two  girls  17  and  26  years  old.  In  two  cases  the 
disease  was  limited  to  the  synovial  membrane.  The  patients,  as 
a  rule,  regain  good  use  of  limb  with  movable  joint,  and  the 
shortening  is  slight. 

Tubercular  sequestra  in  two  cases  and  in  six  cases  granu- 
lating foci  in  bone.  Eight  of  the  cases  had  completely  recov- 
ered at  the  time  the  report  was  made,  one  died  seven  weeks  after 


TUBERCULOSIS   OF    ANKLE-JOINT    AND    TARSUS. 


489 


operation  of  tubercular  meningitis,  and  two  of  the  cases  were 
progressing  in  a  satisfactory  manner.  In  three  cases  no  short- 
ening was  present ;  in  two  cases  the  shortening  amounted  to  one 
centimetre,  once  one  and  a  half  centimetres,  and  twice  two  centi- 
metres. A  fair  degree  of  mobility  of  joint  existed  in  all  of  the 
cases,  when  a  sufficient  time  had  elapsed,  and  was  expected  in 
the  others.  No  mechanical  support  was  worn  by  any  of  them. 
Boeckel  made  four  synovectomies,  in  children  2  to  4  years  of 
age,  with  permanent  result  and  good  use  of  limb  five  to  seven 
years  after  operation.  The  func- 
tional results  after  resection  and 
arthrectomy  of  the  ankle-joint  are, 
as  a  rule,  satisfactory.  The  short- 
ening, if  any,  is  slight,  and  the 
range  of  motion  all  that  could  be 
wished,  while  the  limb  is  strong 
enough  to  enable  the  patient  to 
walk  great  distances  without  the 
aid  of  mechanical  support.  Bornitz 
("  Ueber  die  Arthrektomie  des  Fuss- 
gelenkes  nach  dem  Konig'schen 
verfahren  und  iiber  eine  neue  Modi- 
fikation  desselben."  Brims, Beitrdge 
zurklin.  CJiirurgie,  Bd.  viii)  reports 
fifteen  arthrectomies  of  the  ankle- 
joint  for  tuberculosis,  of  which  in 
five  cases  the  operation  was  followed  by  local  recurrence.  In 
the  remaining  ten  cases  the  operation  proved  a  perfect  success; 
all  of  the  patients  recovered  with  a  useful  limb,  and  in  some  of 
them  the  functional  result  was  almost  perfect. 

Tarsus. — Until  quite  recently,  tubercular  affections  of  the 
tarsus,  as  a  rule,  were  subjected  to  amputation.  At  the  present 
time  conservative  surgery  is  applied  to  this  part  of  the  foot  to 
the  same  extent  as  in  the  treatment  of  tuberculosis  of  other  bones 
and  joints. 


FIG.  103.— EXCISION  OP  ANKLE- 
JOINT  IN  CHILD  SEVERAL  MONTHS 
AFTER  OPERATION. 


490  TUBERCULOSIS   OP   THE   BONES   AND   JOINTS. 

Primary  Seat  of  Disease. — Of  the  tarsal  bones  the  os  cal- 
cis  is  most  frequently  attacked ;  next  the  proximal  end  of  the 
first  metatarsal  bone ;  the  cuboid  comes  next ;  then  the  astrag- 
alus, and  the  scaphoid  and  cuneiform  last.  •  In  the  os  calcis 


FIG.  104.— EXCISION  OF  THE  Os  CALCIS. 


cheesy  foci  are  more  frequent  than  the  necrotic  form.  In  con- 
nection with  tubercular  disease  of  one  or  more  of  the  tarsal 
bones,  osteoporosis  of  the  remaining  bones  is  a  common  occur- 
rence. 

Resection. — Ignipuncture  and  parenchymatous  injections  of 


FIG.  105.— MIKULICZ-WLADIMIROFF'S  OSTEOPLASTIC  RESECTION  OF  THE  TARSUS. 
INCISION  THROUGH  SOFT  PARTS. 

iodoform  or  balsam  of  Peru  can  be  done,  with  a  fair  hope  of 
success,  in  all  early  cases  of  tarsal  tuberculosis.  If  the  disease 
is  limited  to  the  os  calcis  and  does  not  yield  to  conservative 
treatment,  or  has  resulted  in  the  formation  of  fistulous  openings, 


TUBERCULOSIS   OF    ANKLE-JOINT   AND    TARSUS. 


491 


this  bone  should  be  removed  in  its  entirety  by  an  incision  ex- 
tending, from  a  point  below  the  attachment  of  the  tendo  Aehillis, 
along  the  upper  margin  of  the  sole  of  the  foot,  on  the  fibular 
side,  the  whole  length  of  the  bone. 

If  the  disease  involve  both  the  os  calcis  and  astragalus, 
both  of  these  bones  can  be  removed  through  a  similar  incision, 
under  the  same  circumstances.  Functional  result  after  either 
of  these  operations  is  satisfactory.  In 
extensive  disease  of  the  posterior  part  of 
the  tarsus  as  far  back  as  the  ankle,  the 
anterior  part  of  the  foot  can  be  preserved 
by  Mikulicz-Wladimiroff 's  osteoplastic 
resection  of  the  ankle,  with  good  prospects 
of  obtaining  a  useful  limb. 

Chobaut  ("  Contribution  a  la  Chir- 
urgie  du  pied.     De  la  tarsectomie  ante- 


FIG.  106. — BONE  SECTIONS. 


FIG.  107.— POSITION  OF  FOOT  AND 
TOES  AFTER  THIS  OPERATION. 


rieure  totale  et  partielle  dans  les  cas  pathologiques."  Paris, 
1889)  has  given  a  description  of  Ollier's  method  of  performing 
anterior  tarsectomy.  Access  to  the  diseased  bones  is  secured  by 
this  operation  through  four  incisions, — four  to  five  centimetres 
in  length, — made  over  the  dorsum  and  in  the  long  axis  of  the 
foot,  and  in  such  a  manner  as  to  prevent  injury  to  important 
tendons,  vessels,  and  nerves.  The  first  incision  is  commenced 
about  one  centimetre  behind  the  tnberosity  of  the  os  navicularis 
and  carried  to  the  inner  border  of  the  base  of  the  first  metatarsal 


492  TUBERCULOSIS    OF   THE    BONES    AND    JOINTS. 

bone.  The  tendon  of  the  tibialis  anticus  is  drawn  upward  and 
outward  so  as  to  keep  it  out  of  the  line  of  incision.  The  second 
incision  follows  the  inner  margin  of  the  first  tendon  of  the  com- 
mon extensors  of  the  toes  and  extends  to  the  first  interosseous 
space  of  the  metatarsus,  and  passes  along  the  outer  margin  of 
the  first  cuneiform  hone.  In  this  manner  injury  to  the  dorsal 
artery,  which  runs  along  the  outer  border  of  the  tendon,  is 
avoided.  The  third  incision  reaches  from  the  prominence  of 
the  astragalus,  which  can  be  felt  if  the  foot  is  abducted  to  the 
fourth  interosseous  space  of  the  metatarsus.  It  passes  between 
the  third  and  fourth  tendons  of  the  common  extensor  muscle. 
This  incision  is  on  a  level  with  the  junction  of  the  third  cunei- 
form bone  and  the  cuboid.  The  fourth  incision  finally  extends, 
in  the  adult,  two  centimetres  from  the  anterior  border  of  the 
external  malleolus  and  ends  at  the  tuberosity  of  the  fifth  meta- 
tarsal  bone ;  it  extends  along  the  upper  and  inner  margin  of  the 
peronei  muscles.  In  removing  the  diseased  tarsal  bones,  Oilier 
usually  commences  with  the  scaphoid  and  first  cuneiform,  occa- 
sionally with  the  cuboid,  if  this  is  more  extensively  diseased, 
and  consequently  can  be  extracted  with  greater  ease.  Wherever 
it  is  found  necessary,  the  anterior  surface  of  the  calcaneous  and 
astragalus,  as  well  as  tarsal  ends  ol  the  metatarsal  bones,  are 
likewise  removed.  Ilesection  of  the  tarsal  bones  in  front  of  the 
ankle-joint  must  be  done  through  an  anterior  or  long  lateral 
incision.. 

Obalinski  (Centralllatt  f.  Chirnrgie,  October  25,  1890)  de- 
scribes a  new  method  of  incision  for  resection  of  diseased  por- 
tions of  the  tarsus.  The  two  outer  toes  being  taken  by  the 
surgeon,  and  the  three  inner  by  his  assistant,  on  the  right  foot, 
and  vice  versa  on  the  left,  the  knife  is  carried  between  the  third 
and  fourth  metatarsal  bones,  and  then  between  the  cuboid  on 
the  outer  side  and  the  third  cuneiform  and  scaphoid  on  the 
inner  side,  as  far  as  the  astragalus  and  os  calcis.  The  middle 
tarsal  joint  is  now  opened,  and  the  lateral  halves  of  the  foot  are 
drawn  widely  apart  almost  to  a  right  angle  to  its  long  axis  on 


TUBERCULOSIS   OF    ANKLE-JOINT    AND    TARSUS.  493 

either  side.  After  the  removal  of  any  diseased  portions  of  bone, 
other  parts  of  the  foot  are  exposed  to  view,  so  that  all  the  bones 
of  the  tarsus  and  metatarsus  may  be  seen  and  reached,  and  a 
thorough  examination  made  for  diseased  tissue.  After  the  bleed- 
ing has  been  arrested,  the  cavity  of  the  wound  is  stuffed  with 
iodoform  gauze  and  the  two  portions  of  the  foot  are  drawn  to- 
gether and  kept  in  position  by  sutures. 

Gritti  ("Resectio  Dorsalis  Tarso-Metatarsea."  Annals  of 
Surgery,  vol.  ix,  p.  233)  has  devised  a  new  incision  for  the  ex- 
cision of  the  tarsal  bones  when  the  disease  is  located  near  or  at 
the  junction  with  the  metatarsal  bones.  The  operation  is  per- 
formed as  follows  :  A  transverse  incision  of  the  skin  is  made  over 
the  instep,  somewhat  above  the  base  of  the  metatarsal  bones ;  at 
each  end  of  this  an  incision  is  carried,  the  one  along  the  outer  and 
the  other  along  the  inner  border  of  the  foot.  These,  when  com- 
pleted, should  mark  out  the  letter  H.  The  two  rectangular 
flaps  are  reflected  and  the  bones  exposed.  The  navicular  and 
cuboid  bones  are  sawn  across,  in  a  direction  from  the  dorsum 
toward  the  plantar  surface,  and  upon  the  same  level.  In  the 
same  manner  the  metatarsal  bones  are  sawn  through,  and  the 
parts  to  be  removed  loosened  from  their  connections  with  the 
plantar  surface  of  the  foot;  ligature  of  the  anterior  tibial  artery 
will  be  necessary;  the  surfaces  of  the  sawn  bones  are  to  be 
sutured,  as  well  as  the  tendon  of  the  extensor  longus  pollicis, 
and  external  wound  closed.  This  operation  differs  in  several 
details  from  the  procedure  devised  by  Bardenheuer  ("  Die 
Querexcision  der  Fusswurzel-Knochen."  Von  Dr.  J.  Schmidt. 
Mittheilungen  aus  dem  Kolner  Borrger  hospital  von  Prof.  Dr. 
Bardenheuer,  1886). 

Believing  that  tuberculosis  of  the  tarsus  most  frequently 
originates  in  or  affects  the  five  small  bones  at  the  root  of  the 
foot,  Bardenheuer  invariably  extirpates  all  these  bones  in  caries 
of  the  tarsus.  He  makes  a  transverse  incision  over  the  dorsum 
of  the  foot,  from  the  bone  of  the  first  to  that  of  the  fifth  meta- 
tarsal bone,  or  higher  up,  according  to  circumstances.  The 


494  TUBERCULOSIS   OF    THE    BONES    AND    JOINTS. 

tendons  of  the  common,  long,  and  extensor  muscles  of  the  toes, 
of  the  external  interossei  muscles,  and,  sometimes,  that  of  the 
abductor  digit!  minimi  are  cut  through,  together  with  the  smaller 
vessels  and  nerves.  The  entire  flap  having  then  been  dissected 
up,  parallel  cuts  are  made  through  the  entire  bony  portion  of 
the  foot  with  a  saw,  and  at  right  angles  to  its  axis,  and  thus  a 
section  is  taken  out  of  the  middle  of  the  foot  including  all  of  the 
diseased  bones.  The  incisions  are  directed  through  the  sub- 
stance of  the  bone.  After  operation  the  front  part  of  the  foot  is 
Connected  with  the  posterior  portion  only  by  the  plantar  soft 
tissues.  The  two  portions  are  now  approximated,  and  the  skin 
sutured,  or  else,  and  preferably,  tamponade  with  dry  antiseptic 
gauze  is  done,  and  the  parts  united  by  secondary  suturing  after 
the  surfaces  are  covered  with  granulations.  In  the  seventeen 
cases  of  this  operation,  performed  by  Bardenheuer,  recovery 
generally  occurred  without  reaction.  The  anterior  portion  of 
the  foot  could  be  moved  in  two  or  three  weeks,  and  the  toes 
could  be  extended.  In  one  month  recovery  was  complete.  The 
author  believes  that  a  new  articulation  is  foi'rned  between  the 
approximated  bone  surfaces.  With  the  exception  of  three  cases, 
where  secondary  resection  became  necessary,  the  operations  were 
all  successful. 

Isler  ("  Ueber  grosse  atypische  Resectionen  am  Fusse." 
Deutsehe  Zeitsch.  fur  Cldrurgie,  B.  xxxi,  Heft  3  u.  4)  has  col- 
lected one  hundred  and  forty-five  cases  of  extensive  atypical  re- 
section of  the  ankle,  tarsus,  and  metatarsus  from  the  practice 
of  eighty-five  different  surgeons.  Of  this  number  fifteen 
died, — a  mortality  of  10.3  per  cent.  An  excellent  func- 
tional result  was  obtained  in  fifty-nine  cases,  a  good  result  in 
thirty-nine,  a  fair  result  in  eleven  ;  the  ultimate  result  remained 
undetermined  in  twelve,  bad  result  in  nine.  Of  the  latter  cases, 
it  became  necessary  later  to  resort  to  amputation  in  seven.  The 
best  results  were  obtained  in  patients  under  15  years  of  age. 
Kappeler  recommends  an  inner  and  outer  incision,  preserving 
the  tendons,  nerves,  and  vessels  as  far  as  possible. 


TUBERCULOSIS   OF    ANKLE-JOINT    AND    TARSUS-  495 

Ransohoff  ("Tuberculous  Disease  of  the  Tarsus."  Medi- 
cal Neius,  November  29,  1890)  has  tabulated  thirty  operations 
made  for  tarsal  disease,  and  it  is  stated  that,  of  this  number,  in 
fifteen  evidement  was  done,  of  which  but  two  were  successful, 
and  these  were  children.  In  six  the  curetting  was  followed  by 
exacerbation  of  the  previous  conditions.  Of  twelve  excisions, 
four  were  primary,  and  in  three  the  operations  were  made  be- 
fore sinuses  had  formed.  In  these  primary  operations  the  re- 
pair was  more  rapid  than  in  those  in  which  curetting  had 
previously  been  done.  Four  resections  proved  failures, — in 
three  from  recurrence  of  the  disease  and  in  the  fourth  from  the 
uselessness  of  the  foot.  In  two  cases,  patients  aged  12  and  30 
years,  I  removed  all  of  the  short  bones  of  the  foot  for  disease, 
and  obtained  a  useful  foot.  In  the  older  patient  the  lower  end  of 
the  tibia  answered  an  excellent  purpose  as  a  substitute  for  the 
heel,  while  the  articulation  which  formed  between  its  anterior 
surface  and  the  base  of  the  metatarsal  bones  was  movable, 
enabling  the  patient  to  walk  readily  and  gracefully.  Boeckel 
made  seventeen  tarsectomies,  and  in  all  of  them  the  operation 
proved  successful.  In  one  case  he  removed  the  os  calcis  and 
astragalus  in  a  child  3  years  old,  who  became  a  gardener,  and 
when  18  years  of  age  could  walk  sixteen  to  twenty  kilometres 
a  day  with  scarcely  a  limp,  all  movements  of  the  foot  being 
nearly  normal. 

Resection  of  Metatarso-Phalangeal  Joint  of  Big  Toe. — 
Peterson  recommends  ("Ueber  Arthrectomie  des  ersten  Mittel- 
fuss-Zehen  gelenks."  Archiv  f.  kUn.  Cliirurgie,  B.  xxxvii,  S. 
677),  instead  of  the  customary  incision  along  the  inner  aspect 
of  the  joint,  an  incision  between  the  first  and  second  toes 
as  far  as  the  neck  of  the  head  of  the  metatarsal  bone.  The 
cut  is  <made  a  little  nearer  the  great  toe.  Both  toes  are  now 
forcibly  separated  and  the  joint  is  opened.  The  soft  tissues  are 
separated  anteriorly  and  posteriorly  from  both  bones,  without 
dividing  any  muscles  or  tendons.  The  farther  the  dissection  is 
carried,  the  better  the  toe  can  be  adducted;  finally,  the  toe  can 


496  TUBERCULOSIS   OF   THE    BONES    AND    JOINTS. 

be  bent  inward  to  the  extent  that  the  end  of  it  points  backward, 
and  the  joint  is  opened  in  its  entire  extent,  and  can  be  dealt 
with  according  to  the  local  conditions  which  are  presented. 


INDEX. 


Abscess,  tubercular,  49-64 

chemical  analysis,  50 

cold,  4,  377 

cultivation  experiments,  52 

iliac,  360 

inoculation  experiments,  53 

iodoforrnization,  375 

lumbar,  360 

membrane,  55 

migration,  57 

of  joints,  142 

para-articular,  155 

prognosis,  59 

psoas,  360 

secondary  infection,  51 

symptoms  and  diagnosis,  57 

treatment,  60 
incision  and  scraping,  62 
tapping,  61 

Acetabulum,  resection,  450 
Acromegalia,  177 

Acute  miliary  tuberculosis  of  synovial 
membrane,  135 

progressive  tubercular  osteomyelitis, 

86 

Akido-peurastik,  105 
Amputation  of  limb,  332-336 

of  leg  and  arm,  334 

Anatomico-pathological  basis  of  tuber- 
cle, 28,  135 
Ankle-joint,  and  tarsus,  473-496 

resection,  313 
Arthrectomy,  281,  469,  485 
Arthritis,  chronic  fungous,  127,  132 

rheumatic,  175 

syphilitic,  176 

typhoid,  177 
Arthrotomy,  281 

Atrophy  of  bone  and  muscle,  102 
Atypical  resection,  306 

Bacillus  tuberculosis,  22-26,  217 
colored  plates,  22-24 
culture  mediums.  22-24 


32 


Bacillus  tuberculosis,  death-point,  25 
discovery,  4 

pathogenic  effect  of,  on  tissues,  49 
presence  of,  in  affected  tissues,  7 
sporulation,  22 
staining  properties,  22 

Ehrlich's  method,  23 

Frankel's  method,  24 

Gibbes'  method,  23 

Nocard  and  Roux's  method,  24 

Ziehl-Neelsen's  method,  23 
Baker's  pins,  315 

Blood-supply  of  tubercle-nodule,  38 
Bone  tuberculosis,  69-90 
a  secondary  lesion,  74 
caseous  foci  in  bone,  75 
circumscribed,  86 

diffuse  tubercular  osteomyelitis,  85 
etiology,  91-96 
fungous  osteomyelitis,  73 
miliary  tuberculosis,  73 
pathological  varieties  of  tubercular 

osteomyelitis,  73 
pathology     and     morbid     anatomy, 

69 
prognosis,  111-115 

acute  miliary,  114 

amyloid  degeneration,  114 

general  infection,  113 

healing  by  cicatrization,  111 

miliary  diffuse,  114 

re-infection,  111,  112 

spontaneous  healing,  111,  113 
progressive,  86 
secondary,  86 
specific  form  of  chronic  osteomyeli 

tis,  72 

spina  veritosa,  68,  72 
symptoms  and  diagnosis,  97-110 

akido-peurastik,  105 

atrophy  of  limb,  102 

conchiolin  osteomyelitis,  108 

differential  diagnosis,  104 

echinococcus,  107 

(497) 


498 


INDEX. 


Bone     tuberculosis,     symptoms     and 
diagnosis,  epiphysial  multiple 
osteomyelitis,  108 
inoculation  experiments,  105 
pain,  98 
probing,  106 
rachitis,  107 
redness,  102 
sarcoma,  107 
swelling,  100 
synovial,  107 
syphilis,  109 
tenderness,  99 
treatment,  116-126 
amputation,  126 
change  of  climate,  116 
creasote,  116 

dietetic  and  hygienic,  116 
early  effective,  116 
flannel  under-clothing,  117 
ignipuncture,  120 

deep  cauterization,  120 

iodofortn,  122 

multiple  punctures,  122 

Paquelin  cautery,  122,  125 

strict  antisepsis,  122 
intra-articular  injections,  238 
iodide  of  iron,  116 
iodine,  116 

iodoform,  118,  122,  125 
local,  117 
medical,  116 
operative,  116 

out-door  air  and  exercise,  117 
parenchymatous    injections,     118, 
238,  376 

balsam  of  Peru,  118 

carbolic  acid,  119 

corrosive  sublimate,  119 

exploring  syringe,  119 

formic  acid,  119 
'glycerin,  119 

iodoform,  118 

olive-oil,  119 

strict  antisepsis,  119 
physiological  rest,  117 

Rauchfuss's  swing,  118 

Sayre's    plaster-of-Paris    jacket, 
118 


Bone  tuberculosis,  treatment,  potassic 

iodide,  116 
removal  of  osseous  tubercular  foci, 

123 

antiseptic  dressing,  125 
bone-chips,  125 
capillary  drain,  125 
chisel  and  sharp  spoon,  124 
elevated  position,  125 
Esmarch's  elastic  constrictor,  124 
excision,  126 

exploratory  punctures,  124 
extirpation,  126 
immobilization,  125 
iodine-water,  125 
iodoform,  125 
posterior  splint,  125 
salt-water  baths,  117 
sea-bathing,  116 
tuberculin,  215-237 
tubercular  necrosis,  80 

spontaneous  cure,  85 
periostitis,  89 
Bones  and  joints,  1 
of  face,  349 
of  head,  340 
of  nose,  350 
of  skull,  340 
of  trunk,  353 

Caries,  87,  144,  183,  454 

fungosa,  86 

necrotica,  454 

sicca,  89,  129,  398 
Caseation,  46-48 

of  inflammatory  product,  21 
Caseous  foci  in  bone,  75 
Cell  theory,  specific,  28 
Chondritis,  tubercular,  147 
Chronic  fungous  arthritis,  127 
Clavicle,  387 
Cold  abscesses,   tubercular   nature,   4, 

50,  57,  142 

Colored  plates,  22-25,  177,  217 
Conchiolin  osteomyelitis,  108 
Coxitis,  171,  428,  431 
Cranial  vault,  341 
Crude  tubercle,  27 
Cysts,  popliteal,  178 


INDEX. 


499 


Death  point  of  bacillus  tuberculosis,  25 
Diastasis,  454 

Discovery  of  bacillus  tuberculosis,  4-6 
Distribution  of  tubercle  bacilli  in  nod- 
ule, 39 

Echinococcus,  107,  179 
Elbow-joint,  313,  406 

resection,  313,  408 
Empyema  of  joints,  142 
Encysted  tubercle,  28 
Epiphysial  multiple  osteomyelitis,  108 
Epitholioid -cells,  34 
Etiology  of  bone  tuberculosis,  91-96 

of  joint  tuberculosis,  157-165 

Face,  bones  of,  349 
Fistula  of  trochauter  major,  123 
Formation  of  tubercle  nodule,  37 
Fungous  arthritis,  132 

articuli,  283 

osteomyelitis,  73 
granulating  focus,  73 

synovitis,  132,  138,  474 

Giant-cells,  30 

amoeboid  nature,  34 

colored  plate,  25 

destructive  function,  33 
Gluck's  ivory  joint,  463 
Granular  tubercle,  27,  73 
Gray  tubercle,  29 
Growth  of  tubercle-nodules,  40 

Head,  bones  of,  340 
Hip  disease,  428 
Hip-joint,  313,  428 

resection,  313,  441 
Histogenesis  of  tubercle,  41-45 
Histology  of  tubercle,  27^0 
History  of  tuberculosis  of  bones  and 

joints,  1-6 
Hydrops  fibrinosis,  136 

mono-articular,  137 

tubercular,  134,  136 
Hypertrophy  of  tissues,  140 

Iliac  abscess,  360 
Implantation  experiments,  13 

of  granulation  tissue,  14 
Infection  of  joints,  10 


Infectiousness  of  tuberculosis,  3 

Inferior  maxilla,  351 

Inoculation  experiments,  11-20,  105 

Joint  tuberculosis,  127-144,  397 
acute  rniliary,  135 

anatomico-pathological  varieties,  135 
etiology,  157-165 

age  an  important  factor,  163 

essential  cause,  165 

exciting  causes,  163 

hereditary  origin,  157 

rheumatism  as  a  cause,  164 

susceptibility,  159 

transmission,  160 
hypertrophy,  140 
osteo-arthritis,  129 

two  forms,  129 

pathological  changes  in  bone  in,  153 
pathology  and  morbid  anatomy,  127 
primary  synovial  tuberculosis,  132 

tubercular  hydrops,  134,  136 
prognosis,  180-184 

complications,  184 

hereditary  form,  183 

local  recurrence,  180 

neglected  cases,  184 

septic  infection,  184 
secondary  tuberculosis  of  knee-joint, 

140 
symptoms  and  diagnosis,  166-179 

coxitis,  171 

differential  diagnosis,  174 

dislocation  and  other  deformities, 
172 

echinococcus,  179 

fluctuation,  168 

local  symptoms,  168 

muscular  contraction,  170 

osteitis  deformans,  177 

pain,  173 

popliteal  cysts,  178 

rheumatic  arthritis,  175 

sarcoma  of  joints,  179 

shortening  of  limb,  172 

swelling,  166 

syphilitic  arthritis,  176 

typhoid  arthritis,  177 
synovitis  hyperplastica,  137,  139 


500 


INDEX. 


Joint  tuberculosis,  treatment,  185-191, 

238-254 

change  of  climate,  188 
general,  185 
hygienic,  185 
internal  medication,  189 
local,  192-214 

antiseptic  fomentations,  209 
brisement  force,  205 
cold,  208 
compression,  207 
counter-irritation,  211 
electricity,  211 
extension,  198 

apparatus,  203 
external,  206 
immobilization,  19,6 
massage,  210 
rest,  192 

in  bed,  195 
tapping,  212 
operative,  281-291 
arthrectomy,  281 
arthrotomy,  281 
resection,  292 
atypical,  306 
typical,  310 
parenchymatous  and  intra-articular 

injections,  238-280,  426 
action  of  iodoform,  263 
antiseptic  precautions,  239 
arsenious  acid,  241 
balsam  of  Peru,  244 
camphorated  naphthol,  245 
carbolic  acid,  240 
chloride  of  zinc,  243 
clinical  results,  255 
conclusions,  278 
corrosive  sublimate,  242 
experimental  studies,  248 
iodine  tincture,  239 
iodoform,  247 
action  of,  263 
injections,  262 
cases  recently  treated,  269 
indications,  265 
irrigation,  239 
phosphate  of  lime,  243 
points  to  be  remembered,  267 


Joint    tuberculosis,    treatment,    injec- 
tions, Pravaz  syringe,  238 
tincture  of  iodine,  239 
trocar,  238 

post-operative,  337-339 
tuberculin,  215-237 

Koch's  syringe,  215 
tubercular  empyema  of  joints,  142 
Joints  and  bones,  224 

Knee-joint,  226,  313,  452-472 
resection,  313,  455,  459,  467 
Koch's  syringe,  215 
Kyphosis,  363 

Laniinectomy,  378 

Leucocytes,  29 

Lipoma  arborescens  tuberculosum,  141 

Lumbar  abscess,  360 

Macrocytes,  31 

Meniscitis  tuberculosa,  150 

Microbic  cause  of  tubercular  inflamma- 
tion, 27 

Microscopical    structure    of     diseased 
tissue,  21 

Miliary  tubercle,  27,  73,  114,  135 
in  pia  mater,  42 

Milk  of  tubercular  cows,  12 

Minute  anatomy  of  tubercle,  29 

Morbus  coxarius,  428 

Mother-of-pearl  osteomyelitis,  108 

Myelitis  tuberculosa,  380 

Myeloplaques,  32 

Nasal  bones,  350 
Necrosis,  80 
Nodule,  tubercle,  37 

Os  calcis,  excision,  490 

sagittal  section,  473 
Osteitis  deformans,  177 

colored  plate,  177 
Osteo-arthritis,  129 
Osteoclasts,  32 
Osteomyelitis,  acute  progressive,  86 

chronic,  72 

conchiolin,  108 

diffuse  tubercular,  85 
•  epiphysial  multiple,  108 

fungous,  73 


INDEX. 


-  /-  G  r~ 
P-H? 

'/£// 


501 

firW, 


Osteomyelitis,  mother-of-pearl,  108 

pathological  varieties,  73 

rapid  form,  87 

tubercular  453 

of  astragalus,  474 
Osteophthoria,  1 
Osteospongiosis,  1 

Osteotuberculosis  of  elbow-joint,  130 
Otitis  media  tuberculosa,  229 

Psedarthrocace,  1 

Para-articular  tubercular  abscess,  155 
Paralysis,  365 
Parasynovial  abscess,  155 
Pathological  changes,  153 
Pelvic  bones,  385 
Peri-articular  abscess,  155 
Periostitis,  tubercular,  89 
Phthisical  sputum,  12 
Plates,  22-25,  177,  217 
Platycytes,  34 
Popliteal  cysts,  178 
Pott's  disease,  353 

Preparation  from  tissue-juice  of  inocu- 
lation tubercle,  25 
Primary  synovial  tuberculosis,  132,  142 

tubercle,  30 
Prognosis  of  bone  tuberculosis,  111-115 

of  joint  tuberculosis,  180-184 
Proofs  establishing,  7-21 
Pseudo-tuberculosis,  5 
Psoas  abscess,  360 

Rachitis,  107 

Resection,  143,  292-305,  399 
atypical  and  typical,  306-315 
Baker's  pins,  315 
complete  or  typical,  292 
history,  292 
immediate  and  remote  results,   316- 

331 

indications  for,  294 
of  acetabulum,  450 
of  ankle-joint,  313,  474,  484 

history,  474 
of  elbow-joint,  313,  408          ^ 

history,  408 
of  hip-joint,  312,  440 

history,  441 
of  knee-joint,  313,  455,  459,  467 


Resection  of  knee-joint,  history,  455 
of  metatarso-phalangeal  joint  of  big 

toe,  495 
of  shoulder-joint,  313,  399 

history,  399 
of  tarsus,  490 
of  wrist-joint,  313,  418 

history,  418 
partial  or  atypical,  292 
reproduction  of  joint-structures  after, 

299 

results,  316-331 
shortening  of  limb,  296 
Reticulum,  35 

Rheumatic  arthritis  of  joints,  175 
Ribs,  393 
Rice-bodies,  141,  145 

Sacro-iliac  disease,  386 
Sagittal  section  of  os  calcis,  473 
Sarcoma,  107 

of  joints,  178 
Scapula,  389 
Scoliosis,  365 
Scrofula  and  tuberculosis,    distinction 

between,  9 
Secondary  tuberculosis  of  knee-joint, 

140 

Shortening  of  limb,  296,  466 
Shoulder-joint,  397 

resection  of,  313 
Skull,  bones  of,  340 
Specific  cell  theory,  28 
Sphenoid  bone,  349 

Spina  ventosa,  1,   68,   72,  98,  100,  154, 
423 

treatment,  426 
Spinal  column,  353 
Spondylitis,  tubercular,  353 

angular  curvature  of  spine,  364 

causes,  353 

destruction  of  vertebrae,  363 

kyphosis,  363 

paralysis,  365 

pathology  and  morbid  anatomy,  356 

prognosis,  368 

scoliosis,  365 

symptoms  and  diagnosis,  361,  367 
pain,  361 

temperature,  368 


<*s 


INDEX. 


^Spptidylitis,  treatment,  370 
carbolic  acid,  376 
chloride  of  zinc,  376 
corrosive  sublimate,  376 
counter-irritation,  370 
iodoform  ether,  376 
iodoformization  of  abscess,  375 
naphthol  camphor,  376 
operative,  376 
counter-openings,  378 
incision  and  scraping  of  abscess, 

377 

laminectomy,  378 
opening  and  scraping  of  abscess, 

377 

Rauchfuss's  apparatus,  372 
rest  and  extension,  371 
salol  ether,  376 
Say  re's  apparatus,  374 
Sputum,  phthisical,  12 
Sternum,  391 
Strumous  arthritis,  127 
Surgical  tuberculosis,  8 
Symptoms  and  diagnosis  of  bone  tuber- 
culosis, 97-110 

of  joint  tuberculosis,  166-179 
Synovectomy,  469 
Synovial  tuberculosis,  107,  135 
of  knee-joint,  225- 
special  points  in  pathology  of,  145- 

156 
para-articular    tubercular    abscess, 

155 
pathological   changes  in  bone    in 

joint  tuberculosis,  153 
rice-bodies,  145 
tubercular  chondritis,  147 
Synovitis,  fungous,  474 
hyperplastica  granulosa,  132,  137 
Lsevis  S.  Pannosa,  137 
tuberosa,  139 
pannous,  148 

suppurativa  tuberculosa,  142 
tubercular,  130,  452 
Syphilis,  109 
Syphilitic  arthritis  of  joints,  176 

Tarsus,  489 
Temporal  bones,  345 


Traumatic  dissemination  of  tubercular 

process,  322 

Treatment  of  tuberculosis,  bones,  116- 
126 

local,  117 

medical,  116 

operative,  116,  126 
joints,  238-280,  370 

local,  192 

operative,  281 

post-operative,  337 

tubercular,  215 
Trunk,  bones  of,  353 
Tubercle,  anatomico-pathological  basis, 

28 
bacilli  containing  spores,  22 

from  tubercular  cavity,  23 
corpuscle,  28 
crude,  27 
granular,  27 
gray,  29 
histogenesis,  41 
histology,  27 
miliary,  27,  114,  135 
minute  anatomy,  29 
nodule,  arrangement  of  cells,  37 
colored  plate,  37 

blood-supply,  38 

distribution  of  bacilli  in,  39 

formation,  37 

growth,  40 
primary,  30 
reticular,  36 
yellow,  29 

Tubercular  abscess,  49 
chondritis,  147 
destruction  of  vertebrae,  363 
empyema  of  joints,  142,  155 
fistula,  57 
hy  drops,  134,  136 
inflammation,  microbic  cause,  27 
nature  of  cold  abscess,  4 
necrosis,  81 
osteomyelitis,  72,  453 
periostitis,  89 

process,  traumatic  dissemination,  322 
pus,  8 

pyarthrosis,  142 
sequestrum,  81 


INDEX. 


503 


Tubercular  spondylitis,  353 

synovitis,  130,  452 
Tuberculin  treatment,  215-237 
dangers  attending  its  use,  235 
description,  215 
diagnostic  value,  232 
effect  of  remedy,  215 

colored  plate,  217 
general  remarks,  232 
joints  and  bones,  224 
Koch's  syringe,  215 
laryngeal  tuberculosis,  229 
protestation  against  further  use,  236 
pulmonary  phthisis,  229,  231 
reaction,  21 
synovial  tuberculosis   of  knee-joint, 

225 

therapeutic  value,  234 
Tuberculocidin,  237 
Tuberculosis,  acute  miliary,  114 
infectiousness,  3 
microbic  origin,  4 
of  ankle-joint  and  tarsus,  473-496 
arthrectomy,  485 
excision,  489 
primary  location,  473 
resection,  474,  484 
history  of  operation,  474 
incision,  475 
modern  operation,  475 
results  after  operation,  488 
of  bones  and  joints,  1 
artificial  production,  15 
association,  in  other  organs,  20 
etiology,  91-96,  157-165 
history,  1-6 

local  treatment,  117,  192-214 
medical  treatment,  116 
of  trunk,  353-384 
operative  treatment,  116,  281-291 
pathology  and  morbid  anatomy,  69, 

127 

prognosis,  111,  180-184 
reaction  of  tuberculin,  21 
symptoms  and  diagnosis,  97,  166- 

179 

topography,  65-68 
treatment,    116-126,    185-191,    238- 
254 


Tuberculosis  of  clavicle,  387 
of  elbow-joint,  406 
resection  and  arthrectomy,  408 
history  of  operation,  408 
incision,  409 
modern  operation,  409 
results  after,  416 
splints  used  after  resection,  414 
temporary  resection   of  olecranon, 

410 

of  hip-joint,  228,  428-451 
age,  428 

primary  location,  428 
prognosis,  434 
symptoms,  430 
treatment,  435 
arthrectomy,  440 
extension  and  fixation,  435 
extra-articular  operations,  438 
resection,  440 
history  of  operation,  441 
incision,  442 
modern    operative    technique, 

443 

of  acetabulum,  450 
results  after  operation,  448 
Sayre's  long  hip-splint,  437 
Thomas'  splint,  436 
Volkmann's  splint,  437 
of  joints  of  upper  extremity,  397-427 
of  knee-joint,  226,  313,  452-472 
age  and  primary  location,  452 
arthrectomy,  469 
resection-,  455,  459,  467 
history  of  operation,  455 
incision,  456 

modern  operative  technique,  457 
direct  fixation  of  resected  ends, 

461 

drill  and  bone-nails,  461 
ivory  joint,  463 
line  of  section,  462 
results  after  operation,  464 

shortening  of  limb,  466 
of  pelvic  bones,  385 
of  ribs,  393 
of  scapula,  389 
of  shoulder-joint,  397 
resection,  399 


504 


INDEX. 


Tuberculosis   of  shoulder-joint,  resec- 
tion, history  of  operation,  399 
incision,  401 
modern  operation,  402 
of  special  bones,  340-352 
bones  of  face,  349 
of  head,  340 
of  skull,  340 
cranial  vault,  341 
inferior  maxilla,  351 
nasal  bones,  350 
sphenoid  bone,  349 
temporal  bone,  345 
of  sternum,  391 
of  tarsus,  489 

primary  seat  of  disease,  490 
resection,  490 
of  metatarso-phalangeal  joint  of 

big  toe,  495 
of  wrist-joint,  417 
resection,  418 
clinical  studies,  420 


Tuberculosis  of  wrist-joint,   resection, 

history  of  operation,  418 
incision,  418 
parasitic  nature,  4 
proofs  establishing,  7-21 
spina  ventosa,  423 

treatment,  426 
synovial,  107 
Tumor  albus,  2,  127 

cause,  2 

Typhoid  arthritis,  177 
Typical  resection,  310 

Vegetations  of  tubercle  bacilli,  24 
Vertebrae,  353 

White  swelling,  2,  128 

two  sorts,  128 
Wrist-joint,  313,  417 

resection,  313,  418 

Yellow  tubercle,  29 


REVISED  EDITION,  1892. 


ti^J 

1 


1=1 

1 


(3 


ATALOGUE 


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PAGK 

Annual    of    the   Universal   Medical 

Sciences 27,  28,  29 

Anatomy. 

Practical  Anatomy — Boenning 4 

Structure  of  the  Central  Nervous  Sys- 
tem— Edinger 8 

Charts  of  the  Nervo- Vascular  System- 
Price  and  Eagleton 17 

Synopsis  of  Human  Anatomy — Young  .   .  25 

Bacteriology. 

Bacteriological  Diagnosis — Eisenberg    .   .      8 

Clinical  Charts. 

Improved  Clinical  Charts— Bashore  ....      3 

Domestic  Hygiene,  etc. 

The  Daughter:  Her  Health,  Education, 
and  Wedlock— Capp 5 

Consumption  :  How  to  Prevent  it,  etc. — 
Davis 7 

Plain    Talks    on    Avoided    Subjects- 
Guernsey  9 

Heredity,  Health,  and  Personal  Beauty — 
Shoemaker 21 

Electricity. 

Practical  Electricity  in  Medicine  and 
Surgery— Liebig  and  Robe 12 

Electricity  in  the  Diseases  of  Women— 
Massey 13 

Fever. 

Fever:  its  Pathology  and  Treatment- 
Hare  10 

Hay  Fever — Sajous 20 

Gynecology. 

lessons  in  Gynecology— Goodell 9 

Practical  Gynecology— Montgomery   ...     82 

t  Heart,  Lungs,  Kidneys,  etc. 

Diseases   of    the    Heart,   Lungs,    and 

Kidneys— Davis 32 

Diseases  of  the  Heart  and  Circulation  in 
Children— Keating  and  Edwards  ...  12 

Diabetes:    its    Cause,    Symptoms,    and 

Treatment— Purdy 17 

Hygiene. 

Climatology   of    Southern    California — 

Remondino 18 

Text-Book  of  Hygiene— Robe" 19 

Materia  Medica  and  Thera- 
peutics. 

Hand-Book  of  Materia  Medica,  Pharmacy, 
and  Therapeutics — Bowen 4 

Ointments  and  Oleates — Shoemaker  ...     21 

Materia  Medica  and  Therapeutics— Shoe- 
maker    22 

International  Pocket  Medical  Formulary — 
Witherstine 26 


Miscellaneous. 

PAGE 

Book  on  the  Physician  Himself— Cathell  .  5 

Oxygen— Demarqtiay  and  Wallian    ....  7 
Record-Book  of  Medical  Examinations  for 

Life-Insurance — Keating H 

The  Medical  Bulletin,  Monthly 2 

Physician's  Interpreter 13 

Circumcision — Remondino 18 

Medical  Symbolism — Sozinskey 23 

International  Pocket  Medical  Formulary — 

Witherstine 26 

The   Chinese :    Medical,    Political,    and 

Social — Coltman (j 

A  B  C  of  the  Swedish  System  of  Educa- 
tional Gymnastics— Nissen 15 

Lectures  on  Auto-Intoxication— Bouchard  32 

Nervous  System,  Spine,  etc. 

Spinal  Concussion — Clevenger 6 

Structure  of  the  Central  Nervous  System 

— Edinger g 

Epilepsy :  its  Pathology  and  Treatment- 
Hare  10 

Lectures  on  Nervous  Diseases — Ranney    .  30 


Obstetrics. 


Childbed  :  its  Management ;  Diseases  and 

Their  Treatment— Man  ton     32 

Eclampsia— Michener  and  ethers 13 

Obstetric  Synopsis — Stewart 24 

Physiognomy. 

Practical   and    Scientific    Physiognomy— 
Stanton 30 

Physiology. 

Physiology  of  Domestic  Animals— Smith  .     23 

Surgery  and  Surgical  Operations. 

Practice  of  Surgery — Packard 32 

Tuberculosis  of  tlieBones  and  Joints — Senn  32 

Circumcision — Remondino 18 

Principles  of  Surgery — Senn 20 

Swedish  Movement  and  Massage. 

Swedish   Movement  and    Massage  Treat- 
ment— Nissen 15 

Throat  and  Nose. 

Journal  of  Laryngology  and  Rhinology 
Hay  Fever — Sajous 


11 
20 

Diphtheria,  Croup,  etc. — Sanne 25 

Lectures  on  the  Diseases  of  the  Nose  and 
Throat.    Sajous 31 

Venereal  Diseases. 

Syphilis  To-day  and  in  Antiquity — Buret  4  &  32 
Neuroses  of   the  Genito-UrinaVy  System 
in  the  Male — Ultzmann 24 

Veterinary. 

Age  of  Domestic  Animals — Huidekoper   .     11 
Physiology  of  Domestic  Animals — Smith  .     23 

Visiting-Lists  and  Account- 
Books. 

Medical  Bulletin  Visiting-List  or  Physi- 

sicians'  Call-Record 14 

Physicians'  All-Requisite  Account-Book  .     10 


MEDICAL  BULLETIN.   A  Monthly  Journal  of  Medicine  and  Surgery. 

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Hand-Book  of  Materia  Medica,  Pharmacy, 
and  Therapeutics. 

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366  pages  about  as  much  sound  and  valu- 
able information  on  the  subjects  indi- 


cated in  its  title  as  could  well  be  crowded 
into  the  compass. — St.  Louti  Medical  and 
Surgical  Journal. 


BURET 

SYPHILIS    ln  Ancicnt  and  Prehistoric  Times. 

WITH  A   CHAPTER  ON  THE   RATIONAL  TREATMENT   OF  SYPHILIS   IN  THE 
NINETEENTH  CENTURY. 

By  DR.  F.  BURET,  Paris,  France.  Translated  from  the  French,  with  the 
author's  permission,  with  notes,  by  A.  H.  OHMANN-DUMESNIL,  Professor  of 
Dermatology  and  Syphilology  in  the  St.  Louis  College  of  Physicians  and  Surgeons. 

No.  12  in  the  Physicians'  and  Students'  Ready-Reference  Series.  230  pages. 
12mo.  Extra  Dark-Blue  Cloth. 

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in  the  Middle  Ages  and  in  modern  times,  now  in  active  preparation},  gives  the  most  com- 
plete history  of  Syphilis  from  prehistoric  times  up  to  the  Christian  Era.  ' 

The  subject  throughout  is  treated  in  a  clear,  concise  manner,  and  readers 
will  find  many  things  which  are  historically  new. 

In  order  to  give  some  idea  of  the  contents  of  this  first  volume,  the  following 
are  cited  as  among  the  subjects  treated  : — 

In  What  does  Syphilis  Consist?  Origin  of  the  Word  Syphilis.  The  Age  of 
Syphilis.  Syphilis  in  Prehistoric  Times.  Tchoang. — Syphilis  Among  the  Chinese 
5000  Years  Ago.  Kasa. — Syphilis  in  Japan  in  the  Ninth  Century  B.C.  Syphilis 
Among  the  Ancient  Egyptians,  1400  B.C.  Syphilis  Among  the  Ancient  Agbyrians 
and  Babylonians.  Syphilis  Among  the  Hebrews  in  Biblical  Times.  Upadansa. — 
Syphilis  Among  the  Hindoos,  1000  B.C.  Sukon. — Syphilis  Among  the  Greeks. 
Ficus. — Syphilis  at  Rome  under  the  Caesars.  Conclusion  :  Rational  Treatment  of 
Syphilis  in  the  Nineteenth  Century. 

(4) 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


CAPP 


The  Daughter. 

HOMELY  SUGGESTIONS  TO  MOTHERS  AND  DAUGHTERS. 


and 


By  WILLIAM  M.  CAPP,  M.D.,  Philadelphia.  This  is  just  such  a  book 
as  a  family  physician  would  advise  his  lady  patients  to  obtain  and  read. 
It  answers  many  questions  which  every  busy  practitioner  of  medicine 
has  put  to  him  in  the  sick-room  at  a  time  when  it  is  neither  expedient 
nor  wise  to  impart  the  information  sought. 

It  is  complete  in  one  beautifully  printed  (large,  clear  type)  12mo 
volume  of  150  pages.  Attractively  oound  in  Extra  Cloth. 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.00,  net;  In  Grea, 
Britain,  5s.  6i ;  France,  6  fr.  20. 


In  the  144  pages  allotted  to  him  he  has  com- 
pressed an  amount  of  homely  wisdom  on  the 
physical,  mental,  and  moral  development  of 
the  female  child  from  birth  to  maturity  which 
is  to  be  found  elsewhere  in  only  the  great 
book  of  experience.  It  is,  of  course,  a  book 
for  mothers,  but  is  one  so  void  of  offense  in 
expression  or  ideas  that  it  can  safely  be  recom- 
mended for  all  whose  minds  are  sufficiently 
developed  to  appreciate  its  teachings. — Phila- 
delphia Public  ^Ledger. 

Many   delicate   subjects   are   treated   with 


skill  and  in  a,  manner  which  cannot  strike  any 
one  as  improper  or  bold.  The  absolute  ignor- 
ance in  which  most  young  girls  are  allowed  to 
exist,  even  until  adrilt  life,  is  often  productive 
of  much  misery,  both  mental  and  physical. 
Quite  a  number  of  books  written  by  physi- 
cians for  popular  use  have  been  prepared  in 
such  a  way  that  the  professional  man  can  read 
between  the  lines  strong  bids  for  popular 
favor,  etc.  These  objectionable  features  will 
not  be  found  in  Dr.  Capp's  brochure,  and  for 
this  reason  it  is  worthy  the  confidence  of 
physicians. — Medical  News. 


CATHELL 

Book  on  the  Physician  Himself 

AND  THINGS  THAT  CONCERN  HIS  REPUTATION  AND  SUCCESS. 

By  D.  W.  CATHELL,  M.D.,  Baltimore,  Md.  Being  the  NINTH  EDITION 
(enlarged  and  thoroughly  revised)  of  the  "  Physician  Himself,  and  what 
he  should  add  to  his  Scientific  Acquirements  in  order  to  Secure  Success." 
In  one  handsome  Octavo  Volume  of  298  pages,  bound  in  Extra  Cloth. 

Thousands  of  physicians  have  won  success  in  their  chosen  profession 
through  the  aid  of  this  invaluable  work. 

This  remarkable  book  has  passed  through  eight  (8)  editions  in  less 
than  five  years.  It  has  just  undergone  a  thorough  revison  by  the  author, 
who  has  added  much  new  matter  covering  many  points  and  elucidating 
many  excellent  ideas  not  included  in  former  editions. 

Price,  post-paid,  in  the  United  States  and  Canada,  $2.00,  net ;  in  Great 
Britain,  11s.  6i ;  France,  12  fr.  10. 


I  am  most  favorably  impressed  with  the 
wisdom  and  force  of  the  points  made  in  "The 
Physician  Himself,"  and  believe  the  work  in 
the"  hands  of  a  young  graduate  will  greatly  en- 
hance his  chances  for  professional  success. — 
From  Prof.  D.  Hayes  Agnew,  Phila.,  Pa. 

We  strongly  advise  every  actual  and  intend- 
ing practitioner  of  medicine  or  surgery  to  have 
"  The  Physician  Himself,"  and  the  more  it  in- 
fluences his  future  conduct  the  better  he  will 
be.— From  the,  Canada  Medical  and  Surgical 
Journal,  Montreal. 

In  the  present  edition  the  entire  work  has 
been  revised  and  some  new  matter  introduced. 
The  publisher's  part  is  well  done;  paper  is 
good  and  the  print  Inrge:  altogether  it  is  a 
very  readable  and  enjoyable  book.— Montreal 
Medical  Journal 


We  have  read  it  carefully  and  regret  much 
that  we  had  not  done  so  earlier  and  followed 
its  precepts.  The  book  is  full  of  good  advice. 
Get  it  at  once. — Pacific  Record  of  Medicine 
and  Surgery. 

We  cannot  imagine  a  more  profitable  invest, 
ment  for  the  junior  practitioner  than  the  pur- 
chase and  careful  studv  of  "The  Physiciac 
Himself." — Occidental  Medical  Times. 

To  the  physician  who  has  discovered  that 
there  is  something  else  besides  dry  book -learn- 
ing needed  to  make  him  a  desirable  visitor  at 
the  bedside,  we  command  this  volume,  that  he 
may  assimilate  some  of  the  ready  crystallized 
worldly  wisdom  which  otherwise  he  may  be 
many  years  acquiring  by  natural  processes.— 
North  Carolina  Medical  Journal. 


(5; 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


CLEVENGER 

Spinal  Concussion. 

SURGICALLY   CONSIDERED  AS  A   CAUSE  OF   SPINAL   INJURY,  AND  NEURO- 

LOGICALLY  RESTRICTED  TO  A  CERTAIN  SYMPTOM  GROUP,  FOR  WHICH 

is    SUGGESTED  THE   DESIGNATION    ERICHSEN'S  DISEASE, 

AS  ONE  FORM  OP  THE  TRAUMATIC  NEUROSES. 

By  S.  V.  CLEVENGER,  M.D.,  Consulting  Physician  Reese  and  Alexian 
Hospitals ;  Late  Pathologist  County  Insane  Asylum,  Chicago,  etc. 

Special  features  consist  in  a  description  of  modern  methods  of  diag- 
nosis by  Electricity,  a  discussion  of  the  controversy  concerning  hysteria, 
and  the  author's  original  pathological  view  that  the  lesion  is  one  involv- 
ing the  spinal  sympathetic  nervous  system. 

Every  Physician  and  Lawyer  should  own  this  work. 

In  one  handsome  Royal  Octavo  Volume  of  nearly  400  pages,  with 
thirty  Wood-Engravings. 

Price,  post-paid,  in  United  States  and  Canada,  $2.50,  net ;  in  Great 
Britain,  14s. ;  in  France,  15  fr. 


This  work  really  does,  if  we  may  be  per- 
mitted to  use  a  trite  and  hackneyed  expres- 
sion, "fill  a  long-felt  want."  The  subject  is 
treated  in  all  its  bearings;  electro-diagnosis 


receives  a  large  share  of  attention,  and  the 
chapter  devoted  to  illustrative  cases  will  be 
found  to  possess  especial  importance. — Med- 
ical Weekly  Review. 


COLTMAN 


THE  CHINESE: 


Their  Present  and  Future; 
Medical,  Political,  and  Social. 


By  ROBERT  COLTMAN,  JR.,  M.D.,  Siu-geon  in  Charge  of  the  Presby- 
terian Hospital  and  Dispensary  at  Teng  Chow  Fu  ;  Consulting  Phy- 
sician of  the  American  Southern  Baptist  Mission  Society,  etc. 

Beautifully  printed  in  large,  clear  type,  illustrated  with  Fifteen  Fine 
Engravings  on  Extra  Plate  Paper,  from  photographs  of  persons,  places, 
and  objects  characteristic  of  China. 

In  one  Royal  Octavo  volume  of  212  Pages.  Handsomely  bound  in 
Extra  Cloth,  with  Chinese  Side  Stamp  in  gold. 

Price,  post-paid,  in  United  States  and  Canada,  $1.75,  net;  in  Great 
Britain,  10s. ;  in  France,  12  fr.  20. 


The  Chinaman  is  a  source  of  absolute  curi- 
osity to  the  American,  and  anything  in  regard 
to  his  relationship  to  the  medical  profession 
will  prove  more  than  usuullv  attractive  to  the 
average  doctor.  Such  is  the  case  with  the 
work  oef ore  us.  It  is  difficult  to  put  it  aside 
after  one  has  begun  to  read  it. — Memphis  Med. 
Monthly. 

Dr.  Coltman  has  written  a  very  readable 
book,  illustrated  with  reproductions  of  photo- 
graphs taken  by  himself.— Boston  Med.  and 
Surff.  Journal. 

Attached  to  a  number  of  hospitals  and  dis- 
pensaries, he  has  had  ample  opportunity  to 
observe  the  medical  aspect  <>£  the  Chinese. 
The  most  prevalent  diseases  are  such  as  affect 
the  alimentary  tract  and  eye  troubles.  Renal 
troubles  are  also  frequent.  Skin  diseases  are 
abundant  and  syphilis  is  far  from  infrequent. 


Erysipelas  is  rare  andenteric  fever  infrequent. 
Cholera  appears  in  epidemics  and  is  then 
frightfully  fatal.  Leprosy,  of  course,  is  com- 
mon, and  the  author  states  that  it  cannot  be 
contagious,  as  is  supposed  by  many,  or  it 
would  assume  a  terrible  prevalence  in  China, 
where  lepers  are  permitted  to  go  about  free. 

We  will  not  further  mention  the  subjects 
discussed  in  this  excellent  book.  The  style  of 
the  author  is  very  interesting  and  taking,  and 
much  information  is  given  in  an  entertaining 
manner.  The  political  situation  is  very  intelli- 
gently handled  in  its  various  bearings.  The 
photo-engravings  are  handsome  and  well-ex- 
ecuted, the  book  in  general  being  gotten  up  in 
a  very  artistic  manner.  We  can  heartily  com- 
mend" this  work  not  only  to  physicians,  but  to 
intelligent  lay  readers. — St.  Louis  Medical 
Review. 


(6) 


Medical  Publications  of  The  F.  A.  Davis  Co,,  Philadelphia, 

DAVIS 

How  to  Prevent  it  and  How  to 
Live  with  it. 

ITS   NATURE,  CAUSES,  PREVENTION,  AND  THE   MODE   OF   LIFE,  CLIMATE, 
EXERCISE,  FOOD,  AND  CLOTHING  NECESSARY  FOR  ITS  CURE. 

By  N.  S.  DAVIS,  JR.,  A.M.,  M.D.,  Professor  of  Principles  and  Practice  of 
Medicine,  Chicago  Medical  College  ;  Physician  to  Mercy  Hospital,  Chicago ; 
Member  of  the  American  Medical  Association,  etc. 

This  plain,  practical  treatise  thoroughly  discusses  the  prevention  of  Con- 
sumption, Hygiene  for  Consumptives,  gives  timely  suggestions  concerning  the 
different  climates  and  the  important  part  they  play  in  the  treatment  of  this  disease, 
etc.,  etc., — all  presented  in  such  a  succinct  and  intelligible  style  as  to  make  the 
perusal  of  the  book  a  pleasant  pastime. 

In  one  neat  12mo  volume  of  143  pages.  Handsomely  bound  in  Extra  Cloth, 
with  Back  and  Side  Stamps  in  Gold. 

Price,  post-paid,  in  United  States  and  Canada,  75  Cents,  net ;  in  Great 
Britain,  4s. ;  in  France,  4  fr. 

His  directions  are  given  in  such  a  manner  as 


The  questions  of  heredity,  predisposition, 
prevention,  and  hygienic  treatment  of  con- 
sumption are  simply  and  sensibly  dealt  with. 
The  chapters  on  how  to  live  with  tuberculosis 
are  excellent. — Indiana  Medical  Journal. 

The  author  is  very  thorough  in  his  dis- 
cussion of  the  subject,  and  the  practical  hints 
which  he  gives  are  of  real  worth  and  value. 


to  make  life  enjoyable  to  a  consumptive 
patient  and  not  a  burden,  as  is  too  frequently 
the  case.—  Weekly  Medical  Review. 

There  is  much  good  ordinary  common 
sense  in  this  book  of  only  150  pages.  The  part 
of  the  brochure  devoted  to  Climatology  is  espe- 
cially commendable. — Denver  Medical  Times. 


DEMARQUAY 

f\       f\  A  Practical  Investigation  of  the  Clinical 

UP    UXYQCn.         and  Therapeutic  Value  of  tne  Gases 
J  **  in  Medical  and  Surgical  Practice, 

WITH  ESPECIAL  REFERENCE  TO  THE  VALUE  AND  AVAILABILITY  OF  OXYGEN 
NITROGEN,  HYDROGEN,  AND  NITROGEN  MONOXIDE. 

By  J.  N.  DEMARQUAY,  Surgeon  to  the  Municipal  Hospital,  Paris,  and  of  the 
Council  of  State  ;  Member  of  the  Imperial  Society  of  Surgery,  etc.  Translated, 
with  notes,  additions,  and  omissions,  by  SAMUEL  S.  WALLIAN,  A.M.,  M.D. ;  Ex- 
President  of  the  Medical  Association  of  Northern  New  York  ;  Member  of  the  New 
York  County  Medical  Society,  etc. 

In  one  handsome  Octavo  Volume  of  316  pages,  printed  on  fine  paper,  in  the 
best  style  of  the  printer's  art,  and  illustrated  with  21  Wood-Cuts. 

Price,  post-paid,  in  United  States  and  Canada,  Cloth,  $2.00,  net;  Half- 
Russia,  $3.00,  net.  In  Great  Britain,  Cloth,  lls.  6d. ;  Half-Russia, 
17s.  61  In  Prance,  Cloth,  12  fr.  40;  Ealf-Eussia,  18  fr.  GO. 

For  gome  years  past  there  has  been  a  growing  demand  for  something  more 
satisfactory  and  more  practical  in  the  way  of  literature  on  the  subject  of  aero- 
therapeutics.  On  all  sides  professional  men  of  standing  and  ability  are  turning 
their  attention  to  the  use  of  the  gaseous  elements,  as  remedies  in  disease,  as  well 
as  sustainers  in  health.  In  prosecuting  their  inquiries,  the  first  hindrance  has 
been  the  want  of  any  reliable  or  satisfactory  literature  on  the  subject. 

This  work,  translated  from  the  French  of  Professor  Demarquay,  contains 
also  a  very  full  account  of  recent  English,  German,  and  American  experiences, 
prepared  by  Dr.  Samuel  S.  Wallian,  of  New  York,  whose  experience  in  this  field 
has  been  more  extensive  than  that  of  any  other  American  writer  on  the  subject. 

The  book  should  be  widely  read,   for  to 
many  it  will    bring  the   addition  of   a   new 


This  is  a  handsome  volume  of  300  pages, 
in  large  print,  on  good  paper,  and  nicelv  illus- 
trated. Although  nominally  pleading  for  the 
use  of  oxygen  inhalations,  the  author  shows  in 
a  philosophical  manner  how  much  greater 
good  physicians  might  do  if  they  more  fully 
appreciated  the  value  of  fresh-air  exercise  and 

water,  especially  in  diseases  of  the  lungs,  kid-       , 

neys,  and  skin.    We  commend  its  perusal  to  I    the  improvements  in  therapeutics. — Medical 
our  readers.— The  Canada  Medical  Record.       '    News. 

(7) 


weapon    to   their    therapeutic    armament. — 
Northwestern  Lancet. 

Altogether  the  book  is  a  valuable  one, 
which  will  be  found  of  service  to  the  busv 
practitioner  who  wishes  to  keep  abreast  of 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


EISENBERG 


TABULAR  AIDS  FOR  USE  IN  PRACTICAL  WORK. 

By  JAMES  EISENBERG,  Ph.D.,  M.D.,  Vienna.  Translated  and  augmented, 
with  the  permission  of  the  author,  from  the  second  German  Edition,  by  NORVAL 
H.  PIERCE,  M.D.,  Surgeon  to  the  Out-Door  Department  of  Michael  Reese 
Hospital  ;  Assistant  to  Surgical  Clinic,  College  of  Physicians  and  Surgeons, 
Chicago,  111. 

Nearly  200  pages.  In  one  Royal  Octavo  volume,  handsomely  bound  in 
Cloth  and  in  Oil-Cloth  (for  laboratory  use). 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.50,  net;  in  Great 
Britain,  8s.  3d.  ;  in  France,  9  fr.  35. 

This  book  is  a  novelty  in  Bacteriological  Science.  It  is  a  work  of  great 
importance  to  the  teacher  as  well  as  to  the  student.  It  will  be  of  inestimable 
value  to  the  private  worker,  and  is  designed  throughout  as  a  practical  guide  in 
laboratory  work.  It  is  arranged  in  a  tabular  form,  in  which  are  given  the  specific 
characteristics  of  the  various  well  established  bacteria,  so  that  the  worker  may,  at 
a  glance,  inform  himself  as  to  the  identity  of  a  given  organism. 

There  is  also  an  appendix,  in  which  is  given,  in  a  concise  and  practical  form, 
the  technique  employed  by  the  best  laboratories  in  the  cultivation  and  staining 
of  bacteria;  the  composition  and  preparation  of  the  various  solid,  semi-solid,  and 
fluid  media,  together  with  their  employment  ;  a  complete  list  of  stains  and  re- 
agents, with  fbrmulje  for  same  ;  the  methods  of  microscopic  examination  of 
bacteria,  etc.  ,  etc.,  etc. 


EDINGER 

Twelve  Lectures  on  the  Structure  of  the 
Central  Nervous  System. 

FOR  PHYSICIANS  AND  STUDENTS. 

By  DR.  LUDWIG  EDINGER,  Frankfort-on-the-Main.  Second  Revised  Edi- 
tion. With  133  Illustrations.  Translated  by  WILLIS  HALL  VITTTJM,  M.D.,  St. 
Paul,  Minn.  Edited  by  C.  EUGENE  RTGGS,  A.M.,  M.D.,  Professor  of  Mental  and 
Nervous  Diseases,  University  of  Minnesota  ;  Member  of  the  American  Neuro- 
logical Association. 

The  illustrations  are  exactly  the  same  as  those  used  in  the  latest  German 
edition  (with  the  German  names  translated  into  English),  and  are  very  satisfac- 
tory to  the  Physician  and  Student  using  the  book. 

The  work  is  complete  in  one  Royal  Octavo  Volume  of  about  250  pages, 
bound  in  Extra  Cloth. 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.75,  net ;  in  Great 
Britain,  10s. ;  in  France,  12  fr.  20. 


One  of  the  most  instructive  and  valuable 
works  on  the  minute  anatomy  of  the  human 
brain  extant.  It  is  written  in  the  form  of 
lectures,  profusely  illustrated,  and  in  clear 
language.— The  Pacific  Record  of  Medicine 


Since  the  first  works  on  anatomy,  up  to  the 
present  day.  no  work  has  appeared  on  the  sub- 
ject of  the  general  and  minute  anatomy  of  the 


and  Surgery. 

Every  point  is  clearly  dwelt  upon  in  the  text. 


succeeded  in  transforming  the  mazy  wilder- 
ness of  nerve-fibres  and  cells  into  a  district  of 
well-marked  pathways  and  centres,  and  by  so 
doing  has  made  a  pleasure  out  of  an  anatom- 
ical bugbear.— The  Southern  Medical  Record. 


and  where  description  alone  might  leave  a 
subject  obscure  clever  drawings  and  diagrams 
are  introduced  to  render  misconception  of  the 


central  nervous  system  so  complete  and  ex-  ||  author's  meaning  impossible.  The  book  is 
haustive  as  this  work  of  Dr.  Ludwig  Edinger.  n  eminently  practical.  It  unravels  the  intricate 
Being  himself  an  original  worker,  and  having  entanglement  of  different  tracts  and  paths  in 
the  benefits  of  such  masters  as  Stilling,  Wei-  a  way  that  no  other  book  has  done  so  explic- 
geit,  tieilach,  Meynert,  and  others,  Tie  has  ||  itly  or  so  concisely. — Northwestern  Lancet. 

(8) 


Medical  Publications  of  The  F.  A.  Davis  Co..  Philadelphia. 


GOODELL 

;  Lessons  in  Gynecology. 

By  WILLIAM  GOOUELL,  A.M.,  M.D.,  etc.,  Professor  of  Clinical  Gyne- 
cology in  the  University  of  Pennsylvania. 

This  exceedingly  valuable  work,  from  one  of  the  most  eminent 
specialists  and  teachers  in  gynecology  in  the  United  States,  is  now 
offered  to  the  profession  in  a  much  more  complete  condition  than  either 
of  the  previous  editions.  It  embraces  all  the  more  important  diseases 
and  the  principal  operations  in  the  field  of  g3-necology,  and  brings  to 
bear  upon  them  all  the  extensive  practical  experience  and  wide  reading 
of  the  author.  It  is  an  indispensable  guide  to  every  practitioner  who 
has  to  do  with  the  diseases  peculiar  to  women.  Third  Edition.  With 
112  illustrations.  Thoroughly  revised  and  greatly  enlarged.  One  volume, 
large  octavo,  578  pages. 

Price,  in  United  States  and  Canada,  Cloth,  $5.00;  Full  Sheep,  $6.00.    Discount, 

20  per  cent.,  making  it,  net,  Cloth,  $4.00 ;  Sheep,  $180.    Postage,  27 

cents  extra.     Great  Britain,  Cloth,  22s.  6i  ;  Sheep,  28s., 

post-paid.    France,  30  fr.  80. 


It  is  too  good  a  book  to  have  been  allowed  to 
remain  out  of  print,  and  it  has  unquestionably 
been  missed.  The  author  has  revised  the  work 
with  special  care,  adding  to  each  lesson  such 
fresh  matter  as  the  progress.-in  the  art^ren- 
dered  necessary,  and  he  has  enlarged  it  by  the 
insertion  of  six  new  lessons.  This  edition  will, 
without  question,  be  as  eagerly  sought  for  as 
were  its  predecessors. — American  Journal  of 
Obstetrics. 

His  literary  style  is  peculiarly  charming. 
There  is  a  directness  and  simplicity  about  it 
which  is  easier  to  admire  than  to  copy.  His 
chain  of  plain  words  and  almost  blunt  expres- 
sions, his  familiar  comparison  and  homely 
illustrations,  make  his  writings,  like  his  lec- 


tures, unusually  entertaining.  The  substance 
of  his  teachings  we  regard  as  equally  excel- 
lent.— Philadelphia  Medical  and  Surgical 
Reporter. 

Extended  mention  of  the  contents  of  the 
book  is  unnecessary ;  suffice  it  to  sarv  that 
every  important  disease  found  in  the  female 
sex  is  taken  up  and  discussed  in  a  oomiupn- 
sense  kind  of  a  way.  We  wish  every  physician 
in  America  could  'read  and  carry  out  the  sug- 
gestions of  the  chapter  on  "the  sexual  rela- 
tions as  causes  of  uterine  disorders — conjugal 
onanism  and  kindred  sins.''  The  department 
treating  of  nervous  counterfeits  of  uterine 
diseases  is  a  most  valuable  one. — Kansas  City/ 
Medical  Index. 


GUERNSEY 

Plain  Talks  on  Avoided  Subjects. 

By  HENRY  N.  GUERNSEY,  M.D.,  formerly  Professor  of  Materia  Medica 
and  Institutes  in  the  Hahnemann  Medical  College  of  Philadelphia;: 
author  of  Guernsey's  "  Obstetrics,"  including  the  Disorders  Peculiar  to 
Women  and  Young  Children  ;  Lectures  on  Materia  Medica,  etc.  The 
following  Table  of  Contents  shows  the  scope  of  the  book : 

CONTENTS. — Chapter  I.  Introductory.  II.  The  Infant.  III.  Child- 
hood. IV.  Adolescence  of  the  Male.  V.  Adolescence  of  the  Female. 
VI.  Marriage:  The  Husband.  VII.  The  Wife.  VIII.  Husband  and 
Wife.  IX.  To  the  Unfortunate.  X.  Origin  of  the  Sex.  In  one  neat 
16mo  volume,  bound  in  Extra  Cloth. 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.00 ;  Great  Britain, 

6s. ;  France,  6  fr.  20. 

It) 


Medical  Publications  of  TJie,  F.  A.  Daw's  Co.,  Philadelphia. 


HAKE 


BEING  AN  ESSAY  TO  WHICH  WAS  AWARDED  A  PRIZE  OF  FOUR  THOUSAND 

FRANCS  BY  THE  ACADEMIE  ROYALE  DE  MEDECINE  DE  BELGLQUE, 

DECEMBER  31,  1889. 

By  HOBART  AMORT  HARE,  M.D.  (Univ.  of  Penna.),  B.Sc.,  Professor  oi 
Materia  Medica  and  Therapeutics  in  the  Jefferson  Medical  College,  Phila.  ; 
Physician  to  St.  Agnes'  Hospital  and  to  the  Children's  Dispensary  of  the  Chil- 
dren's Hospital  ;  Laureate  of  the  Royal  Academy  of  Medicine  in  Belgium,  of 
the  Medical  Society  of  London,  etc.  ;  Member  of  the  Association  of  American 
Physicians. 

No.  7  in  the  Physicians'  and  Students'  Ready-Reference  Series.  12mo.  228 
pages.  Neatly  bound  in  Dark -blue  Cloth. 

Price,  post-paid,  in  United  States  and  Canada,  $1.25,  net ;  in  Great 
Britain,  6s.  6i ;  in  Prance,  7  fr.  75. 

It  is  representative  of  the  most  advanced 
views  of  the  profession,  and  the  subject  is 
pruned  of  the  vast  amount  of  superstition  and 
nonsense  that  generally  obtains  in  connection 
with  epilepsy. — Medical  Age. 

Every  physician  who  would  get  at  the  gist 
of  all  that  is  worth  knowing  on  epilepsy,  and 
•wfaw  would  avoid  useless  research  among  the 
•mass  of  literary  nonsense  which  pervades  all 
medical  libraries,  should  get  this  work."— The 
JSanUarian. 

It-contains  all  that  is  known  of  the  pathology 
of  this  strange  disorderj  a  clear  discussion  of 
the  diagnosis  from  allied  neuroses,  and  the 
•very  latest  therapeutic  measures  for  relief. 


It  is  remarkable  for  its  clearness,  brevity,  and 
beauty  of  style.  It  is,  so  far  as  the  reviewer 
knows,  altogether  the  best  essay  ever  written 
upon  this  important  subject. — Kansas  City 
Medical  Index. 

The  task  of  preparing  the  work  must  have 
been  most  laborious,  but  we  think  that  Dr. 
Hare  will  be  repaid  for  his  efforts  by  a  wide 
appreciation  of  the  work  by  the  profession ; 
for  the  book  will  be  instructive  to  those  who 
have  not  kept  abreast  with  the  recent  litera- 
ture upon  this  subject.  Indeed,  the  work  is  a 
sort  of  Dictionary  of  epilepsy — a  reference 
guide-book  upon  the  subject. — Alienist  and 
Neurologist. 


HARE 

Fever:  Its  Pathology  and  Treatment. 

BEING  THE  BOYLSTON  PRIZE  ESSAY  OP  HARVARD  UNIVERSITY  FOR  1890. 
CONTAINING  DIRECTIONS  AND  THE  LATEST  INFORMATION  CON- 
CERNING   THE    USE    OF    THE    So-CALLED    ANTI- 
PYRETICS IN  FEVER  AND  PAIN. 

By  HOBART  AMORY  HARE,  M.D.  (Univ.  of  Penna.),  B.Sc.,  Professor  of 
Materia  Medica  and  Therapeutics  in  the  Jefferson  Medical  College,  Phila.; 
Physician  to  St.  Agnes'  Hospital  and  to  the  Children's  Dispensary  of  the  Chil- 
dren's Hospital;  Laureate  of  the  Royal  Academy  of  Medicine  in  Belgium,  of  the 
Medical  Society  of  London,  etc.;  Member  of  the  Association  of  American 
Physicians. 

No.  10  in  the  Physicians'  and  Students'  Ready-Reference  Series.  12mo. 
Neatly  bound  in  Dark-blue  Cloth. 

Illustrated  with  more  than  25  new  plates  of  tracings  of  various  fever  cases, 
showing  beautifully  and  accurately  the  action  of  the  Antipyretics.  The  work 
also  contains  35  carefully  prepared  statistical  tables  of  249  cases  showing  the 
untoward  effects  of  the  antipyretics. 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.25,  net;  in  Great  Britain, 
6s.  6d. ;  in  Prance,  7  fr.  75. 

As  is  usual  with  this  author,  the  subject  is 
thoroughly  handled,  and  much  experimental 
and  clinical  evidence,  both  from  the  author's 
experience  and  that  of  others,  is  adduced  in 
support  of  the  view  taken. — New  York  Medical 
Abstract. 

The  author  has  done  an  able  piece  of  work 
in  showing  the  facts  as  far  as  they  are  known 
concerning  the  action  of  antipyrin(  anti- 
febrin,  phenacetin,  thallin,  and  salicylic  acid. 
The  reader  will  certainly  find  the  work  one  of 

(10) 


Such  books  as  the  present  one  are  of 
to  the  student,  the  scientific  therapeuti 

tVia    (ronoral     r*t*'inf-i tir»nov    nlil/o      ft\r    inn 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


HUIDEKOPER 

Age  of  the  Domestic  Animals. 

BEING   A  COMPLETE   TREATISE  ON  THE   DENTITION  OF    THE   HORSE,  Oxj 

SHEEP,  HOG,  AND  DOG,  AND  ON  THE  VARIOUS  OTHER  MEANS  OF 

DETERMINING  THE  AGE  OF  THESE  ANIMALS. 

By  RUSH  SHIPPEN  HUIDEKOPER,  M.D.,  Veterinarian  (Alfort,  France)  ;  Professor  of 
Sanitary  Medicine  and  Veterinary  Jurisprudence,  American  Veterinary  College,  New  York  ; 
Late  Dean  of  the  Veterinary  Department,  University  of  Pennsylvania. 

Complete  in  one  handsome  Royal  Octavo  volume  of  225  pages,  bound  in  Extra  Cloth. 
Illustrated  with  200  engravings. 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.75,  net ;  in  Great 
Britain,  10s. ;  in  France,  12  fr.  20. 

This  work  presents  a  careful  study  of  all  that  has  been  written  on  the  subject  from 
the  earliest  Italian  writers.  The  author  has  drawn  much  valuable  material  from  the  ablest 
English,  French,  and  German  writers,  and  has  given  his  own  deductions  and  opinions, 
•whether  they  agree  or  disagree  with  such  investigators  as  Bracy  Clark,  Siuionds  (in  Eng- 
lish), Girard,  Chauveau,  Leyh,  Le  Coque,  Goubaux,  and  Barrier  (iu  German  and  French). 

The  literary  execution  of  the  book  is  very 
satisfactory,  the  text  is  profusely  illustrated, 
and  the  student  will  find  abundant  means  in 
the  cuts  for  familiarizing  himself  with  the 
various  aspects  presented  by  the  incisive 
arches  during  the  different  stages  of  life. 
Illustrations  do  not  always  illustrate ;  these 
do. — Amer.  Vet.  Review. 

Although  written  primarily  for  the  veteri- 


narian,  this  book  will  be  of  interest  to  the 
dentist,  physiologist,,  anatomist,  and  physician. 
Its  wealth  of  illustration  and  careful  prepara- 
tion are  alike  commendable.— Chicago  Med. 
Recorder. 

It  is  profusely  illustrated  with  200  engrav- 
ings, and  the  text  forms  a  study  well  worth  the 
price  of  tlie  book  to  every  dental  practitioner. 
— Ohio  Journal  of  Dental  Sciences. 


AN  ANALYTICAL  RECORD  OF   CURRENT    LITERATURE    RELATING  TO  THE 
THROAT,  NOSE,  AND  EAR.     ISSUED  ON  THE  FIRST  OF  EACH  MONTH. 

Edited  by  DR.  NORRIS  WOLFENDEN,  of  London,  and  DR.  JOHN  MACINTTRE,  of  Glas- 
gow, with  the  active  aid  and  co-operation  of  Drs.  Dundas  Grant,  Barclay  J.  Baron,  and 
Hunter  Mackenzie.  Besides  those  specialists  in  Europe  and  America  who  have  so  ably 
assisted  in  the  collaboration  of  the  Journal,  a  number  of  new  correspondents  have  under- 
taken to  assist  the  editors  in  keeping  the  Journal  up  to  date,  and  furnishing  it  with  matters 
of  interest.  Amongst  these  are  :  Drs.  Sajous,  of  Philadelphia ;  Middlemass  Hunt,  of 
Liverpool ;  Mellow,  of  Rio  Janeiro  ;  Sedziak,  of  Warsaw  ;  Draispul,  of  St.  Petersburg,  etc. 
Drs.  Michael,  Joal,  Holger  Mygind,  Prof.  Massei,  and  Dr.  Valerius  Idelsou  will  still  collab- 
orate the  literature  of  their  respective  countries. 

Price,  13s.  or  $3.00  per  annum  (inclusive  of  Postage).    For  single  copies,  however, 
a  charge  of  Is.  31  (30  Cents)  will  be  made.    Sample  Copy,  25  Cents. 


KEATING 

Record-Book  of  Medical  Examinations 

FOR  LIFE-INSURANCE. 

Designed  by  JOHN  M.  KEATING,  M.D. 

This  record-book  is  small,  neat,  and  complete,  and  embraces  all  the  principal  points 
that  are  required  by  the  different  companies.  It  is  made  in  two  sizes,  viz.  :  No.  1,  covering 
one  hundred  (100)  examinations,  and  No.  2,  covering  two  hundred  (200)  examinations. 
The  size  of  the  book  is  7  x  3%  inches,  and  can  be  conveniently  carried  in  the  pocket. 

U.  S.  and  Canada.       Great  Britain.       France. 

No.  1.    For  100  Examinations,  in  Cloth,    -    -    $  .50,  Net  3s.  6d.          3  fr.  60 

No.  2.    For  200  Examinations,  in  Full 

Leather,  with  Side  Flap,  -    -    -    -      1.00,    "  6s.  6  fr.  20 

(ii) 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


KEATING  and  EDWARDS 

Diseases  of  the  Heart  and  Circulation. 

IN  INFANCY  AND  ADOLESCENCE.     WITH  AN  APPENDIX  ENTITLED  "  CLINICAL 
STUDIES  ON  -SHE  PULSE  IN  CHILDHOOD." 

By  JOHN  M.  KEATING,  M.D.,  Obstetrician  to  the  Philadelphia  Hospital, 
and  Lecturer  on  Diseases  of  Women  and  Children;  Surgeon  to  the  Maternity 
Hospital;  Physician  to  St.  Joseph's  Hospital;  Fellow  of  the  College  of  Physicians 
of  Philadelphia,  etc.;  and  WILLIAM  A.  EDWARDS,  M.D.,  Instructor  fn  Clinical 
Medicine  and  Physician  to  the  Medical  Dispensary  in  the  University  of 
Pennsylvania;  Physician  to  St.  Joseph's  Hospital;  Fellow  of  the  College  of 
Physicians;  formerly  Assistant  Pathologist  to  the  Philadelphia  Hospital,  etc. 

Illustrated  by  Photographs  and  Wood-Engravings.  About  225  pages.  Oc- 
tavo. Bound  in  Cloth. 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.50,  net;  in  Great 
Britain,  8s.  61 ;  in  France,  9  fr.  35. 


Drs.  Keating  and  Edwards  have  produced  a 
work  that  will  give  material  aid  to  every 
doctor  in  his  practice  among  children.  The 
style  of  the  book  is  graphic  and  pleasing,  the 
diagnostic  points  are  explicit  and  exact,  and 
the  therapeutical  resources  include  the  novel- 
ties of  medicine  as  well  as  the  old  and  tried 
agents.— Pittsburgh  Med.  Review. 


It  is  not  a  mere  compilation,  but  a  systematic 
treatise,  and  bears  evidence  of  considerable 
labor  and  observation  on  the  part  of  the 
authors.  Two  fine  photographs  of  dissectioms 
exhibit  mitral  stenosis  and  mitral  regurgita- 
tion  ;  there  are  also  a  number  of  wood-cuts. 
— Cleveland  Medical  Gazette. 


LIEBIG  and  KOHE 

Practical  Electricity  in  Medicine  $  Surgery. 

By  G.  A.  LTEB:G,  JR.,  PH  D.,  Assistant  in  Electricity,  Johns  Hopkins 
University  ;  Lecturer  on  Medical  Electricity,  College  of  Physicians  and  Surgeons, 
Baltimore  ;  Member  of  the  American  Institute  of  Electrical  Engineers,  etc.  ;  and 
GEORGE  H.  ROHE,  M.D.,  Professor  of  Obstetrics  and  Hygiene,  College  of  Physi- 
cians and  Surgeons,  Baltimore  ;  Visiting  Physician  to  Bay  View  and  City  Hos- 
pitals ;  Director  of  the  Maryland  Maternite  ;  Associate  Editor  "Annual  of  the 
Universal  Medical  Sciences,"  etc. 

Profusely  Illustrated  by  Wood-Engravings  and  Original  Diagrams,  and 
published  in  one  handsome  Royal  Octavo  volume  of  383  pages,  bound  in  Extra 
Cloth. 

The  constantly  increasing  demand  for  this  work  attests  its  thorough  relia- 
bility and  its  popularity  with  the  profession,  and  points  to  the  fact  that  it  is 
already  THE  standard  work  on  this  very  important  subject.  The  part  on  Physical 
Electricity,  written  by  Dr.  Liebig,  one  of  the  recognized  authorities  on  the 
science  in  the  United  States,  treats  fully  such  topics  of  interest  as  Storage  Bat- 
teries, Dynamos,  the  Electric  Light,  and  the  Principles  and  Practice  of  Electrical 
Measurement  in  their  Relations  to  Medical  Practice.  Professor  Robe,  who  writes 
on  Electro-Therapeutics,  discusses  at  length  the  recent  developments  of  Electricity 
in  the  treatment  of  stricture,  enlarged  prostate,  uterine  fibroids,  pelvic  cellulitis, 
and  other  diseases  of  the  male  and  female  genito-urinary  organs.  The  applica- 
tions of  Electricity  in  dermatology,  as  well  as  in  the  diseases  of  the  nervous 
system,  are  also  fully  considered. 

Price,  post-paid,  in  the  United  States  and  Canada,  $2.00,  net;  in  Great 
Britain,  lls,  61  ;  France,  12  fr.  40. 


Any  physician,  especially  if  he  be  a  beginner 
in  electro-therapeutics,  will  be  well  repaid  by 
a  careful  study  of  this  work  by  Liebig  and 
Rone.  For  a  work  on  a  special  subject  the 
price  is  low,  and  no  one  can  give  a  good  ex- 
cuse for  remaining  in  ignorance  of  so  impor- 
tant a  subject  as  electricity  in  medicine.  — 
Toledo  Medical  and  Surgical  Reporter. 

The  entire  work  is  thoroughly  scientific  and 
practical,  and  is  really  what  the  authors  have 
aimed  to  produce,  "a  trustworthy  guide  to 
the  application  of  electricity  in  the  practice  of 
medicine  and  Surgery."  —  New  York  Medical 
Times. 


In  its  perusal,  with  each  succeeding  page, 
we  have  been  more  and  more  impressed  with 
the  fact  that  here,  at  last,  we  have  a  treatise 
on  electricity  in  medicine  and  surgery  which 
amply  fulfills  its  purpose,  and  which  is  sure  of 
general  adoption  by  reason  of  its  thorough 
excellence  and  superiority  to  other  works  in- 
tended to  cover  the  same  field. — Pharmaceu- 
tical Era. 

After  carefully  looking  over  this  work,  we 
incline  to  the  belief  that  the  intelligent  physi- 
cian who  is  familiar  with  the  general  subject 
will  be  greatly  interested  and  profited. — 
American  Lancet. 


(12) 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


MASSE  Y 

Electricity  in  the  Diseases  of  Women. 

WITH   SPECIAL   REFERENCE   TO  THE  APPLICATION  OF   STRONG  CURRENTS. 

By  G.  BETTON  MASSEY,  M.D.,  Physician  to  the  Gynaecological  Department 
of  the  Howard  Hospital  ;  late  Electro-therapeutist  to  the  Philadelphia  Orthopaedic 
Hospital  and  Infirmary  for  Nervous  Diseases,  etc.  SECOND  EDITION.  Revised 
and  Enlarged.  With  New  and  Original  Wood-Engravings.  Handsomely  bound 
in  Dark-Blue  Cloth.  240  pages.  12ino.  No.  5  in  the  Physicians'  and  Students' 
Ready -Reference  Series. 

This  work  is  presented  to  the  profession  as  the  most  complete  treatise  yet 
issued  on  the  electrical  treatment  of  the  diseases  of  women,  and  is  destined  to 
fill  the  increasing  demand  for  clear  and  practical  instruction  in  the  handling  and 
use  of  strong  currents  after  the  recent  methods  first  advocated  by  Apostoli.  The 
whole  subject  is  treated  from  the  present  stand-point  of  electric  science  with  new 
and  original  illustrations,  the  thorough  studies  of  the  author  and  his  wide  clinical 
experience  rendering  him  an  authority  upon  electricity  itself  and  its  therapeutic 
applications.  The  author  has  enhanced  the  practical  value  of  the  work  by 
including  the  exact  details  of  treatment  and  results  in  a  number  of  cases  taken 
from  his  private  and  hospital  practice. 

Prke,  post-paid,  in  the  United  States  and  Canada,  $1.50,  net;  in  Great 
Britain,  8s.  6d. ;  in  France,  9  fr.  35. 

A  new  edition  of  this  practical  manual  at- 
tests the  utility  of  its  existence  and  the  recog- 
nition of  its  merits.  The  directions  are  simple, 
easy  to  follow  and  to  put  into  practice;  the 
ground  is  well  covered,  and  nothing  is  assumed, 
the  entire  book  being  the  record  of  expe- 
rience.^Jburnai  of  Nervous  and  Mental 
Diseases. 

It  is  only  a  few  months  since  we  noticed  the 
first  edition  of  this  little  book  ;  and  it  is  only 
necessary  to  add  now  that  we  consider  it  the 


best  treatise  on  this  subject  we  have  seen,  and 
that  the  improvements  introduced  into  this 
edition  make  it  more  valuable  still.— Boston 
Medical  and  Surgical  Journ. 

The  style  is  clear,  but  condensed.  Useless 
details  are  omitted,  the  reports  of  cases  being 
pruned  of  all  irrelevant  material.  The  book 
is  an  exceedingly  valuable  one,  and  represents 
an  amount  of  study  and  experience  which  is 
only  appreciated  after  a  careful  reading. — 
Medical  Record. 


Physicians'  Interpreter. 

IN  FOUR  LANGUAGES  (ENGLISH,  FRENCH,  GERMAN,  AND  ITALIAN). 
SPECIALLY  ARRANGED  FOR  DIAGNOSIS  BY  M.  VON  V. 

The  object  of  this  little  work  is  to  meet  a  need  often  keenly  felt  by  the 
busy,  physician,  namely,  the  need  of  some  quick  and  reliable  method  of  com- 
municating intelligibly  with  patients  of  those  nationalites  and  languages  unfa- 
miliar to  the  practitioner.  The  plan  of  the  book  is  a  systematic  arrangement  of 
questions  upon  the  various  branches  of  Practical  Medicine,  and  each  question  is 
so  worded  that  the  only  answer  required  of  the  patient  is  merely  Yes  or  No. 
The  questions  are  all  numbered,  and  a  complete  Index  renders  them  always 
available  for  quick  reference.  The  book  is  written  by  one  who  is  well  versed-  in 
English,  French,  German,  and  Italian,  being  an  excellent  teacher  in  all  those 
languages,  and  who  has  also  had  considerable  hospital  experience.  Bound  in 
Full  Russia  Leather,  for  carrying  in  the  pocket.  Size,  5  x  2£  inches.  206  pages. 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.00,  net;  in  Gfcreat 
Britain,  6s.  ;  in  France,  6  fr.  20. 


Many  other  books  of  the  same  sort,  with 
more  extensive  vocabularies,  have  been  pub- 
lished, but,  from  their  size,  and  from  their 
being  usually  devoted  to  equivalents  in  Eng- 
lish and  one  other  language  only,  they  have 
not  bad  the  advantage  which  is  pre-eminent  in 
this — convenience.  It  is  handsomely  printed, 
and  bound  in  flexible  red  leather  in  the  form 
of  a  diary.  It  would  scarcely  make  itself  felt 
in  one's  hip-pocket,  and  would  insure  its 
bearer  against  any  ordinary  conversational 


difficulty  in  dealing  with  foreign-speaking 
people,  who  are  constantly  coining  into  our 
city  hospitals.  —  New  York  Medical  Journal. 

This  little  volume  is  one  of.  the  most  inge- 
nious aids  to  the  physician  Vhich  we  have 
seen.  We  heartily  commend  the  book  to  any 
one  who,  being  without  a  knowledge  of  the 
foreign  languages,  la  obliged  to  treat  those 
wbo  do  not  know  our  own  language.  —  St.  Louis 
Courier  of  Medicine. 


(13) 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 

The  Medical  Bulletin  Visiting-List  or 
Physicians'  Call  Record. 

A.RRANQED  UPON  AN  ORIGINAL  AND  CONVENIENT  MONTHLY  AND  WEEKLY 
PLAN  FOR  THE  DAILY  RECORDING  OF  PROFESSIONAL  VISITS. 


Frequent  Rewriting  of  Names  Unnecessary. 

THIS  Visiting-List  is  arranged  so  that  the  names  of  patients  need  be  written 
but  ONCE  a  month  instead  of  FOUR  times  a  month,  as  in  the  old-style  lists. 
By  means  of  a  new  feature,  a  simple  device  consisting  of  STUB  OR  HALF 
LEAVES  IN  THE  FORM  OF  INSERTS,  the  first  week's  visits  are  recorded  in  the  usual 
way,  and  the  second  week's  visits  are  begun  by  simply  turning  over  the  half-leaf 
without  the  necessity  of  rewriting  the  patients'  names.  This  very  easily  under- 
stood process  is  repeated  until  the  month  is  ended  and  the  record  has  been  kept 
complete  in  every  detail  of  VISIT,  CHARGE,  CREDIT,  etc.,  and  the  labor  and  time 
of  entering  and  transferring  names  at  least  THREE  times  in  the  month  has  been 
saved.  There  are  no  intricate  rulings  ;  not  the  least  amount  of  time  can  be  lost 
in  comprehending  the  plan,  for  it  is  acquired  at  a  glance. 

THE  THREE  DIFFERENT  STYLES  MADE. 

The  No.  1  Style  of  this  List  provides  space  for  the  DAILY  record  of  seventy 
different  names  each  month  for  a  year  ;  for  physicians  who  prefer  a  List  that  will 
accommodate  a  larger  practice  we  have  made  a  No.  2  Style,  which  provides 
space  for  the  daily  record  of  105  different  names  each  month  for  a  year,  and  for 
physicians  who  may  prefer  a  Pocket  Record-Book  of  less  thickness  than  either  of 
these  styles  we  have  made  a  No.  3  Style,  in  which  "The  Blanks  for  the  Record- 
ing of  Visits  in  "  have  been  made  into  removable  sections.  These  sections  are 
very  thin,  and  are  made  up  so  as  'to  answer  in  full  the  demand  of  the  largest 
practice,  each  section  providing  ample  space  for  the  DAILY  RECORD  OF  210  DIF- 
FERENT NAMES  for  two  months  ;  or  105  different  names  daily  each  month  for  four 
months  ;  or  seventy  different  names  daily  each  month  for  six  mouths.  Six  sets 
of  these  sections  go  with  each  copy  of  No.  3  STYLE. 

SPECIAL  FEATURES  NOT  FOUND  IN  ANY  OTHER  LIST. 

In  this  No.  3  STYLE  the  PRINTED  MATTER,  and  such  matter  as  the  BLANK 
FORMS  FOR  ADDRESSES  OF  PATIENTS,  Obstetric  Record,  Vaccination  Record, 
Cash  Account.  Birth  and  Death  Records,  etc.,  are  fastened  permanently  in  the 
back  of  the  book,  thus  reducing  its  thickness.  The  addition  of  one  of  these 
removable  sections  does  not  increase  the  thickness  more  than  an  eighth  of  an  inch. 
This  brings  the  book  into  such  a  small  compass  that  no  one  can  object  to  it  on 
account  of  its  thickness,  as  its  bulk  is  VERY  MUCH  LESS  than  that  of  any  visiting- 
list  ever  published.  Every  physician  will  at  once  understand  that  as  soon  as  a 
section  is  full  it  can  be  taken  out,  filed  away,  and  another  inserted  without  the 
least  inconvenience  or  trouble.  Extra  or  additional  sections  will  be  furnished  at 
any  time  for  15  cents  each  or  $1.75  per  dozen.  This  Visiting-List  contains  calen- 
dars, valuable  miscellaneous  data,  important  tables,  and  other  useful  printed 
matter  usually  placed  in  Physicians'  Visiting-Lists. 

Physicians  of  many  years'  standing  and  with  large  practices  pronounce  it 
THE  BEST  LIST  THEY  HAVE  EVER  SEEN.  It  is  handsomely  bound  in  fine,  strong 
leather,  with  flap,  including  a  pocket  for  loose  memoranda,  etc.,  and  is  furnished 
with  a  Dixon  lead-pencil  of  excellent  quality  and  finish.  It  is  compact  and  con- 
venient for  carrying  in  the  pocket.  Size,  4x6£  inches. 


IKT   TKIiEE:    STYLES-  NBT  PRICES. 

No.  1.     Regular  size,  to  accommodate  70  patients  daily  each  month  for  one  year,    .     .     .     SI.  25 

No.  J8.    Large  size,  to  accommodate  105  patients  daily  each  month  for  one  year,  .     .     .     .     •!.  5O 

No.  3.    In  which  the  "  Blanks  for  Recording  Visits  in  "  are  in  removable  sections,  .     .     .     SI.  75 

Special  Edition  for  Great  Britain,  without  printed  matter,        ........  4s.  Gd. 

N.  B.  —  The  Recording  of  Visits  in  this  List  may  be  Commenced  at  any  time  during  the  Year. 

(14) 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 
MICHENER 

Hand-Book  of  Eclampsia; 


OR, 
OK 
coxnrvnuuoiM. 

By  E.  MICHENER,  M.D.  ;  J.  H.  STUBBS,  M.D.  ;  R.,B.  EWING,  M.D.  ;  B. 
THOMPSON,  M.D.  ;  S.  STEBBINS,  M.D.     16mo.     Cloth. 


Price,  60  cents,  net ;  in  Great  Britain,  4s.  6d. ;  France,  4  fr.  20. 


A  MANUAL  OF   INSTRUCTION    FOR   GIVING 

Swedish  Movement  $  Massage  Treatment 

By  PROF.  HARTVIG  NISSEN,  late  Director  of  the  Swedish  Health  Institute, 
Washington,  D.  C.  ;  late  Instructor  in  Physical  Culture  and  Gymnastics  at  the 
Johns  Hopkins  University,  Baltimore,  Md.  ;  Instructor  of  Swedish  and  German 
Gymnastics  at  Harvard  University's  Summer  School,  1891,  etc.,  etc. 

This  excellent  little  volume  treats  this  very  important  subject  in  a  practical 
manner.  Full  instructions  are  given  regarding  the  mode  of  applying  the  Swedish 
Movement  and  Massage  Treatment  in  various  diseases  and  conditions  of  the 
human  system  with  the  greatest  degree  of  effectiveness.  This  book  is  indispens- 
able to  every  physician  who  wishes  to  know  how  to  use  these  valuable  handmaids 
of  medicine. 

Illustrated  with  29  Original  Wood-Engravings.  In  one  12mo  volume  of 
128  Pages.  Neatly  bound  in  Cloth. 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.00,  net;  in  Great 
Britain,  6s.  ;  in  France,  6  fr.  20. 


This  manual  is  valuable  to  the  practitioner, 
as  it  contains  a  terse  description  of  a  subject 
but  too  little  understood  in  this  country.  .  . 
The  book  is  got  up  very  creditably.  —  W.  Y. 
Med.  Journal. 

The  present  volume  is  a  modest  account  of 
the  application  of  the  Swedish  Movement  and 
Massage  Treatment,  in  which  the  technique 


of  the  various  procedures  are  clearly  stated  as 
well  as  illustrated  in  a  very  excellent  manner. 
— North  American  Practitioner. 

This  attractive  little  book  presents  the  sub- 
ject in  a  very  practical  shape,  and  makes  it 
possible  for  eVery  physician  to  understand  at 
least  how  it  is  applied,  if  it  does  not  give  him 
dexterity  in  the  art  of  its  application. — Chicago 
Med.  Times. 


the  Same  Author 

A  B  C  of  the  Swedish  System  of 
Educational  Gymnastics. 

A  PRACTICAL  HAND-BOOK  FOR  SCHOOL-TEACHERS  AND  THE  HOME. 

By  HARTVIG  NISSEN. 

The  author  has  avoided  the  use  of  difficult  scientific  terms,  and  made  it 
as  popular  and  plain  as  possible. 

The  fullest  instructions  and  commands  are  given  for  each  exercise,  and 
Seventy-seven  Excellent  Engravings  illustrate  them  and  add  greatly  to  the  practical 
value  of  the  book. 

It  is  complete  in  one  neat,  small  12mo  volume  of  about  125  Pages,  and 
may  be  conveniently  carried  in  the  pocket.  Bound  in  Extra  Flexible  Cloth. 

Price,  post-paid,  in  United  States  and  Canada,  75  Cents,  net ;  in  Great 
Britain,  4s. ;  in  France,  4  fr. 


This  is  one  of  the  books  which  it  is  a  delight 
to  notice,  on  account  of  its  sterling  worth  and 
practical  utility. — Educational  Monthly,  At- 


Tbe  most  intelligent  and  complete  gymnastic 
primer  ever  published.  It  is  perfectly  simple, 
and  any  child  will  be  able  to  comprehend  it. 


lanta,  Ga.  !'  Its  illustrations  of  the  different  movements 

of  the  body  explain  thomselves. — The  Pacific 


We  wish  this  little  book  were  placed  in  the 
hands  of  every  teacher,  and  the  practice  of  its 
exercises  enforced  upon  every  child  of  the 
schools  of  every  State  as  well  as  in  Boston. — 
American  Lancet. 


(15) 


Record  of  Med.  and  Surgery. 

This  small  volume  is  useful  for  physicians, 
students,  and  all  who  may  be  interested  in 
public  health.—  Med.  Bulletin. 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


Physician's  All-Requisite  Time-  and  Labor* 
Saving  Account-Book. 

BEING  A   LEDGER   AND  ACCOUNT-BOOK  FOR   PHYSICIANS'   USE,  MEETING 
ALL  THE  REQUIREMENTS  OF  THE  LAW  AND  COURTS. 

Designed  by  WILLIAM  A.  SEIBERT,  M.D  ,  of  Easton,  Pa. 

Probably  no  class  of  people  lose  more  money  through  carelessly  kept 
accounts  and  overlooked  or  neglected  bills  than  physicians.  Often  detained  at 
the  bedside  of  the  sick  until  late  at  night,  or  deprived  of  even  a  modicum  of  rest, 
it  is  with  great  difficulty  that  he  spares  the  time  or  puts  himself  in  condition  to 
give  the  same  care  to  his  own  financial  interests  that  a  merchant,  a  lawyer,  or 
even  a  farmer  devotes.  It  is  then  plainly  apparent  that  a  system  of  bookkeeping 
and  accounts  that,  without  sacrificing  accuracy,  but,  on  the  other  hand,  ensuring 
it,  at  the  same  time  relieves  the  keeping  of  a  physician's  book  of  half  their 
complexity  and  two-thirds  the  labor,  is  a  convenience  which  will  be  eagerly 
welcomed  by  thousands  of  overworked  physicians.  Such  a  system  has  at  last 
been  devised,  and  we  take  pleasure  in  offering  it  to  the  profession  in  the  form  ot 
The  Physician's  All-Requisite  Time-  and  Labor-  Saving  Account-Book. 

There  is  no  exaggeration  in  stating  that  this  Account-Book  and  Ledger 
reduces  the  labor  of  keeping  your  accounts  more  than  one-half,  and  at  the  same 
time  secures  the  greatest  degree  of  accuraey.  We  may  mention  a  few  of  the 
superior  advantages  of  The  Physician's  All-Requisite  Time-  and  Labor-  Saving 
Account-Book,  as  follows  : — 


First — Will  meet  all  the  requirements 
of  the  law  and  courts. 

Second — Self-explanatory  ;  no  cipher 
code. 

Third — Its  completeness  without  sacri- 
ficing anything. 

Fourth — No  posting  ;  one  entry  only. 

Fifth — Universal ;  can  be  commenced  at 
any  time  of  the  year,  and  can  be 
continued  indefinitely  until  every 
account  is  filled. 

Sixth — Absolutely  no  waste  of  space. 

Seventh — One  person  must  needs  be 
sick  every  day  of  the  year  to  fill 
his  account,  or  might  be  ten  years 
about  it  and  require  no  more  than 
the  space  for  one  account  in  this 
ledger. 

Eighth — Double  the  number  and  many 
times  more  than  the  number  of  ac- 


counts in  any  similar  book  ;  the 
300-page  book  contains  space  for 
900  accounts,  and  the  600-page 
book  contains  space  for  1800  ac- 
counts. 

Ninth — There  are  no  smaller  spaces. 

Tenth — Compact  without  sacrificing 
completeness  ;  every  account  com- 
plete on  same  page — a  decided  ad- 
vantage and  recommendation. 

Eleventh — Uniform  size  of  leaves. 

Twelfth — The  statement  of  the  most 
complicated  account  is'at  once  be- 
fore you  at  any  time  of  month  or 
year— in  other  words,  the  account 
itself  as  it  stands  is  its  simplest 
statement. 

Thirteenth — No  transferring  of  accounts, 
balances,  etc. 


To  all  physicians  desiring  a  quick,  accurate,  and  comprehensive  method  of 
keeping  their  accounts,  we  can  safely  say  that  no  book  as  suitable  as  this  one  has 
ever  been  devised.  A  descriptive  circular  showing  the  plan  of  the  book  will  be 
sent  on  application. 


NET  PRICES,  SHIPPING  EXPENSES  PREPAID. 

No.  1.  300  Pages,  for  900  Accounts  per  Tear, 

Size  10x12,  Bound  in  K -Russia,  Eaised  inu.  s. 


Canada 
(duty  paid). 


Great 
Britain. 


Back  Bands,  Cloth  Sides, 
No.  2.  600  Pages,  for  1800  Accounts  per  Tear, 
S.ize  10x12,  Bound  in  ^-Russia,  Eaised 
Back-Bands,  Cloth  Sides, 

(16) 


$5.00         $5.50         28s. 


8.00 


8.80 


12s. 


France. 

30  fr.  30. 


49  fr.  40 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 
PRICE  and  EAGLETON 

Three  Charts  of  the  Nervo-Vascular  System. 

PART  I. — THE  NERVES.      PART  II. — THE  ARTERIES. 
PART  III. — THE  YEINS. 

A  New  Edition,  Revised  and  Perfected.  Arranged  by  W.  HENRY  PRICE, 
M.D.,  and  8.  POTTS  EAGLETON,  M.D.  Endorsed  by  leading  anatomists.  Clearly 
and  beautifully  printed  upon  extra  durable  paper. 

PAKT  I.  The  Nerves. — Gives  in  a  clear  form  not  only  the  Cranial  and  Spinal  Nerves,  show- 
ing the  formation  of  the  different  Plexuses  and  their  branches,  but  ajfco  the  complete 
distribution  of  the  SYMPATHETIC  NERVES. 

PART  II.  The  Arteries.— Gives  a  unique  grouping  of  the  Arterial  system,  showing  the 
divisions  and  subdivisions  of  all  the  vessels,  beginning  from  the  heart  and  tracing  their 
CONTINUOUS  distribution  to  the  periphery,  and  showing  at  a  glance  the  terminal 
branches  of  each  artery. 

PART  III.  The  Veins.— Shows  how  the  blood  from  the  periphery  of  the  body  is  gradually 
collected  by  the  larger  veins,  and  these  coalescing  forming  still  larger  vessels,  until  they 
finally  trace  themselves  into  the  Right  Auricle  of  the  heart. 

It  is  therefore  readily  seen  that  "The  Nervo-Vascular  System  of  Charts  " 
offers  the  following  superior  advantages  : — 

1.  It  is  the  only  arrangement  which  combines  the  Three  Systems,  and  yet 
each  is  perfect  and  distinct  in  itself. 

2.  It  is  the  only  instance  of  the  Cranial,  Spinal,  and  Sympathetic  Nervous 
Systems  being  represented  on  one  chart. 

8.  From  its  neat  size  and  clear  type,  and  being  printed  only  upon  one  side, 
it  may  be  tacked  up  in  any  convenient  place,  and  is  always  ready  for  freshening 
up  the  memory  and  reviewing  for  examination. 

Price,  post-paid,  in  United  States  and  Canada,  50  cents,  net,  complete ;  in 
Great  Britain,  3s.  6d. ;  in  France,  3  fr.  60. 


For  the  student  of  anatomy  there  can  pos- 
sibly be  no  more  concise  way  of  acquiring  a 
knowledge  of  the  nerves,  veins,  and  arteries 
of  the  human  system.  It  presents  at  a  glance 
their  trunks  and  branches  in  the  great  divis- 
ions of  the  body.  It  will  save  a  world  of  tedi- 
ous reading,  and  will  impress  itself  on  the 
mind  as  no  ordinary  vade  mecum,  even,  could. 


Its  price  is  nominal  and  its  value  inestimable. 
No  student  should  be  without  it. — Pacific 
Record  of  Medicine  and  Surgery. 

These  are  three  admirably  arranged  charts 
for  the  use  of  students,  to  assist  in  memor- 
izing their  anatomical  sudies. — Buffalo  Med. 
and  Surg.  Jour. 


Diabetes:  Its  Cause, Symptoms  a^Treatment 

By  CHAS.  "W.  PURDY,  M.D.  (Queen's  University),  Honorary  Fellow  of  the 
Royal  College  of  Physicians  and  Surgeons  of  Kingston  ;  Member  of  the  College 
of  Physicians  and  Surgeons  of  Ontario  ;  Author  of  "Bright's  Disease  and  Allied 
Affections  of  the  Kidneys  ;"  Member  of  the  Association  of  American  Physicians  ; 
Member  of  the  American  Medical  Association  ;  Member  of  the  Chicago  Academy 
of  Sciences,  etc. 

CONTENTS. — Section"!.  Historical,  Geographical,  and  Climatological  Con- 
siderations of  Diabetes  Mellitus.  II.  Physiological  and  Pathological  Considera- 
tions of  Diabetes  Mellitus  III.  Etiology  of  Diabetes  Mellitus.  IV.  Morbid 
Anatomy  of  Diabetes  Mellitus.  V.  Symptomatology  of  Diabetes  Mellitus.  VI. 
Treatment  of  Diabetes  Mellitus.  VII.  Clinical  Illustrations  of  Diabetes  Mellitus. 
VIII.  Diabetes  Insipidus  ;  Bibliography. 

I2mo.  Dark  Blue  Extra  Cloth.  Nearly  200  pages.  With  Clinical  Illus- 
trations. No.  8  in  the  Physicians'  and  Students'  Ready -Reference  Series. 

Frice,  post-paid,  in  the  United  States  and  Canada,  $1.25,  net;  in  Great 
Britain,  6s.  61 ;  in  France,  7  fr.  75. 

This  will  prove  a  most  entertaining  as  well 
as  most  interesting  treatise  upon  a  disease 


which    frequently 'falls  to  the"  lot  of   every       considers    its  relations   to   the    geographical 

conditions  which  exist  in  the  United  States, 


practitioner.  The  work  has  been  written  with 
a  special  view  of  bringing  out  the  features  of 
the  disease  as  it  occurs  in  the  United  States. 
The  author  has  very  judiciously  arranged  the 
little  volume,  and  it  will  offer  many  pleasant 
attractions  to  the  practitioner,— Nashville 
Journal  of  Medicine  and  Surgery. 


lished  which  have  dealt  with  the  subject  of 
diabetes,  we  know  of  none  which  so  thoroughly 


which  is  more  complete  in  its  summary  of 
the  symptomatology  and  treatment  of  this 
affection.  A  number  of  tables,  showing  the 
percentage  of  sugar  in  a  very  large  number  of 
alcoholic  beverages,  adds  very  considerably  to 


While  many  monographs  have  been  pub- 

(17) 


the  value  of  the  work.— Medical  News. 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 
REMONDINO 

History  of  Circumcision. 

FROM  THE  EARLIEST  TIMES  TO  THE  PRESENT.     MORAL  AND  PHYSICAL 
REASONS  FOR  ITS  PERFORMANCE  ;  WITH  A  HISTORY  OF  EUNUCHISM, 
HERMAPHRODISM,  ETC.,  AND  OF  THE  DIFFERENT  OPERA- 
TIONS PRACTICED  UPON  THE  PREPUCE. 

By  P.  C.  REMONDINO,  M.D.  (Jefferson),  Member  of  the  American  Med- 
ical Association  ;  of  the  American  Public  Health  Association  ;  Vice- 
President  of  California  State  Medical  Society  and  of  Southern  California 
Medical  Society,  etc. 

In  one  neat  12mo  volume  of  346  pages.  Handsomely  bound  in  Extra 
Dark-Blue  Cloth,  and  illustrated  with  two  fine  wood-engravings,  showing 
the  two  principal  modes  of  Circumcision  in  ancient  times.  No.  11  in  the 
Physicians'  and  Students1  Ready -Reference  Series. 

Price,  post-paid,  in  United  States  and  Canada,  $1.25,  net;  in  Great  Britain, 

6s.  6d. ;  in  France,  7  fr.  75. 
A  Popular  Edition  (unabridged),  bound  in  Paper  Covers,  is  also  issued.   Price, 

50  Cents,  net;  in  Great  Britain,  3s. ;  in  France,  3  fr.  60. 

Every  ph}Tsician  should  read  this  book;  he  will  there  find,  in  a 
condensed  and  systematized  form,  what  there  is  known  concerning 
Circumcision.  The  book  deals  with  simple  facts,  and  it  is  not  a  disserta- 
tion on  theories.  It  deals,  in  plain,  pointed  language,  with  the  relation 
that  the  prepuce  bears  to  physical  degeneracy  and  disease,  bases  all  its 
utterances  on  what  has  occurred  and  on  what  is  known.  The  author  has 
here  gathered  from  every  source  the  material  for  his  subject,  and  the 
deductions  are  unmistakable. 

This  is  a  very  full  and  readable  book.  To 
the  reader  who  wishes  to  know  all  about 
the  antiquity  of  the  operation,  with  the  views 
pro  and  con  of  the  right  of  this  appendage  to 
exist,  its  advantages,  dangers,  etc.,  this  is  the 
book. — The  Southern  Clinic. 

The  operative  chapter  will  be  particu- 
larly useful  and  interesting  to  physicians,  as 
it  contains  a  careful  and  impartial  review  of 
all  the  operative  procedures,  from  the  most 


simple  to  the  most  elaborate,  paying  particular 
attention  to  the  subject  of  after-dressings  It 
is  a  very  interesting  and  instructive  work,  and 
should  be  read  very  liberally  by  the  profes- 
sion.— The  Med.  Brief. 

The  author's  views  in  regard  to  circum- 
cision, its  necessity,  and  its  results,  are  well 
founded,  and  its  performance  as  a  prophylactic 
measure  is  well  established. — Columbus  Med. 
Journal. 


By  the  Same  Author 

The  Mediterranean  Shores  of  America. 

SOUTHERN  CALIFORNIA:  ITS  CLIMATIC,  PHYSICAL,  AND  METEOROLOGICAL 

CONDITIONS. 

By  P.  C.  REMONDINO,  M.D.  (Jefferson),  etc. 

Complete  in  one  handsomely  printed  Octavo  volume  of  nearly  175 
pages,  with  45  appropriate  illustrations  and  2  finely  executed  maps  of 
the  region,  showing  altitudes,  ocean  currents,  etc.  Bound  in  Extra  Cloth. 

Price,  post-paid,  in  United  States  and  Canada,  $1.25,  net ;  in  Great  Britain, 

6s.  6d. ;  in  France,  7  fr.  75. 
Cheaper  Edition  (unabridged),  bound  in  Paper,  post-paid,  in  United  States  and 

Canada,  75  Cents,  net ;  in  Great  Britain,  4s. ;  in  France,  5  fr. 
Italy,  of  the  Old  World,  does  not  excel  nor  even  approach  this  region 
in  point  of  salubrity  of  climate  and  all-around  healthfulness  of  environ- 
ment. This  book  fully  describes  and  discusses  this  wonderfully  charming 
country.  The  medical  profession,  who  have  long  desired  a  trustworthy 
treatise  of  true  scientific  value  on  this  celebrated  region,  will  find  in  this 
volume  a  satisfactory  response  to  this  long-felt  and  oft-expressed  wish. 

(18)  ^ 


^_       Medical  Publications  o/  The  I'.  A.  Davis  Co..  P/niaaeipma. 

ROHE 

Text-Book  of  Hygiene. 

A   COMPREHENSIVE  TREATISE  ON  THE  PRINCIPLES  AND  PRACTICE  OP 
PREVENTIVE  MEDICINE  FROM  AN  AMERICAN  STAND-POINT. 

BY  GEORGE  H.  ROHE,  M.D.,  Professor  of  Obstetrics  and  Hygiene  in 
the  College  of  Physicians  and  Surgeons,  Baltimore;  Member  of  the 
American  Public  Health  Association,  etc. 

Eveiy  Sanitarian  should  have  Rohe's  "  Text-Book  of  Hygiene  "  as  a 
work  of  reference. 

Second  Edition,  thoroughly  revised  and  largely  rewritten,  with 
many  illustrations  and  valuable  tables.  In  one  handsome  Royal  Octavo 
volume  of  over  400  pages,  bound  in  Extra  Cloth. 

Price,  post-paid,  in  United  States,  $2.50,  net ;  Canada  (duty  paid),  $2.75, 
net ;  Great  Britain,  14s. ;  France,  16  fr.  20. 

One  prominent  feature  is  that  there  are  no 
superfluous  words ;  every  sentence  is  direct 
to  the  point  sought.  It  is,  therefore,  easy 
reading,  and  conveys  very  much  information 
in  little  space.— The  Pacific  Record  of  Medi- 
cine and  Surgery. 

It  is  unquestionably  a  work  that  should  be 
in  the  hands  of  every  physician  in  the  country, 
and  medical  students  will  find  it  a  most  excel- 
lent and  valuable  text-book.— The  Southern 
Practitioner. 

The  first  edition  was  rapidly  exhausted,  and 
the  book  justly  became  an  authority  to  physi- 
cians and  sanitary  officers,  and  a  text-book 
very  generally  adopted  in  the  colleges  through- 
out America.  The  second  edition  is  a  great 


improvement  over  the  first,  all  of  the  matter 
being  thoroughly  revised,  much  of  it  being 
rewritten,  ana  many  additions  being  made. 
The  size  of  the  book  is  increased  one  hundred 
pages.  The  book  has  the  original  recommenda- 
tion of  being  a  handsomelv-bound,  clearly- 
printed  octavo  volume,  profusely  illustrated 
with  reliable  references  for  every  branch  of 
the  subject  matter. — Medical  Record 

The  wonder  is  how  Professor  Ron  e  has  made 
the  book  so  readable  and  entertaining  with  so 
much  matter  necessarily  condensed.  Alto- 

f ether,  the  manual   is  a  good   exponent  of 
ygiene  and  sanitary  science  from  the  present 
American   stand-point,   and  will    repay  with 
pleasure  and  profit  any  time  that  may  be  given 
to  its  perusal. — University  Medical  Magazine. 


J$y  the  Same  Author 

A  Practical  Manual  of  Diseases 
of  the  Skin. 

By  GEORGE  H.  ROHE,  M.D.,  Professor  of  Materia  Medica,  Thera- 
peutics, and  Hygiene,  and  formerly  Professor  of  Dermatology  in  the 
College  of  Pli3'sicians  and  Surgeons,  Baltimore,  etc.,  assisted  by  J. 
WILLIAMS  LORD,  A.B.,  M.D.,  Lecturer  on  Dermatology  and  Bandaging 
in  the  College  of  Physicians  and  Surgeons ;  Assistant  Physician  to  the 
Skin  Department  in  the  Dispensary  of  Johns  Hopkins  Hospital. 

In  one  neat  12mo  volume  of  over  300  pages,  bound  in  Extra  Dark-Blue 
Cloth.  No.  13  in  the  Physicians'  and  Students'  Ready-Reference  Series. 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.25,  net;  in  Great 
Britain,  6s.  61 ;  in  France,  7  fr.  75. 

The  PRACTICAL  character  of  this  work  makes  it  specially  desirable 
for  the  use  of  students  and  general  practitioners. 

The  nearly  one  hundred  (100)  reliable  and  carefully  prepared  For- 
mulae at  the  end  of  the  volume  add  not  a  little  to  its  practical  value. 

All  the  various  forms  of  skin  diseases,  from  Acne  to  Zoster  (alpha- 
betically speaking),  are  succinctly  yet  amply  treated  of,  and  the  arrange- 
ment of  the  book,  with  its  excellent  index  and  unusually  full  table  of 
contents,  goes  to  make  up  a  truly  satisfactory  volume  for  ready  reference 
in  dail}7  practice. 

(19) 


Medical  Publications  of  The  F.  A.  .Davis  Co.,  Philadelphia. 


SENN 

Principles  of  Surgery. 

By  N.  SENN,  M.D.,  PH.D.,  Professor  of  Practice  of  Surgery  and  Clinical  Surgery  in 
Rush  Medical  College,  Chicago,  111. ;  Professor  of  Surgery  in  the  Chicago  Polyclinic;  At- 
tending Surgeon  to  the  Milwaukee  Hospital ;  Consulting  Surgeon  to  the  Milwaukee  County 
Hospital  and  to  the  Milwaukee  County  Insane  Asylum. 

This  work,  by  one  of  America's  greatest  surgeons,  is  thoroughly  COMPLETE  ;  its 
clearness  and  brevity  of  statement  are  among  its  conspicuous  merit?.  The  author's  long, 
able,  and  conscientious  researches  in  every  direction  in  this  important  field  are  a  guarantee, 
of  unusual  trustworthiness,  that  every  branch  of  the  subject  is  treated  authoritatively,  and  in 
such  a  manner  as  to  bring  the  greatest  gain  in  knowledge  to  the  practitioner  and  student. 

In  one  handsome  Royal  Octavo  volume,  with  109  fine  Wood-Engravings  and  624 
pages. 

United  States.    Canada  (duty  paid).    Great  Britain.  France 


Price  in  Cloth,  $150,  Net 

Sheep  or  i-Russia,       5.50    " 

STEPHEN  SMITH,  M.D.,  Professor  of  Clin- 
ical Surgery  Medical  Department  University 
of  the  City  of  New  York,  writes : — "  I  have 
examined  the  work  with  great  satisfaction, 
and  regard  it  as  a  most  valuable  addition  to 
American  surgical  literature.  There  has  long 
been  great  need  of  a  work  on  the  principles  of 
surgery  which  would  fully  illustrate  the  pres- 
ent advanced  state  of  knowledge  of  the  various 
subjects  embraced  in  this  volume.  The  work 
seems  to  me  to  meet  this  want  admirably." 

LEWIS  A.  SAYRE,  M.D.,  Professor  Ortho- 
paedic Surgery  Bellevue  Hospital  Medical 
College,  New  Y  ork,  writes  : — "  My  Dear  Doctor 
Sen n  :  Your  very  valuable  work  on  surgery, 
sent  to  me  some  time  since,  I  have  studied 
with  great  satisfaction  and  improvement.  1 
congratulate  you  most  heartily  on  having  pro- 
duced the  most  classical  and  practical  work  on 
surgery  yet  published." 

FRANK  J.  LUTZ,  M.D.,  St.  Louis,  Mo.,  says  : 
— "  It  seems  incredible  that  those  who  pretend 
to  teach  have  done  without  such  a  guide 
before,  and  I  do  not  understand  how  our  stu- 
dents succeeded  in  mastering  the  principles  of 
modern  surgery  by  attempting  to  read  our 
obsolete  text-books.  American  surgery  should 
feel  proud  of  the  production,  and  the  present 
generation  of  surgeons  owe  you  a  debt  of 
gratitude." 

WM.  OSLER,  M.D.,  The  Johns  Hopkins  Hos- 
pital, Baltimore,  says: — "You  aertainly  have 
covered  the  ground  thoroughly  and  well,  and 
with  a  thoroughness  I  do  not  know  of  in  any 
similar  work.  I  should  think  it  would  prove 
a  great  boon  to  the  students  and  also  to  very 
many  teachers." 

The  work  is  systematic  and  compact,  without 
a  fact  omitted  or  a  sentence  too  much,  and  it 
not  only  makes  instructive  but  fascinating 
reading.  A  conspicuous  merit  of  Senn's  work 
is  his  method,  his  persistent  and  tireless  search 
through  original  investigations  fqr  additions 


$5.00,  Net 
6.10    " 


24s.  6i 
30s. 


27  fr.  20 
33  fr.  10 


to  knowledge,  and  the  practical  character  of 
his  discoveries. — The  Review  of  Insanity  and 
Nervous  Diseases. 

Every  chapter  is  a  mine  of  information  con- 
taining all  the  recent  advances  on  the  subjects 
presented  in  such  a  systematic,  instructive, 
and  entertaining  style  that  the  reader  will  not 
willingly  lay  it  aside,  but  will  read  and  re-read 
with  pleasure  and  profit. — Kansas  Medical 
Journal. 

After  perusing  this  work  on  several  different 
occasions,  we  have  come  to  the  conclusion  that 
it  is  a  remarkable  work,  by  a  man  of  unusual 
ability.  The  author  seems  to  have  had  a  very 
large  personal  experience,  which  is  freely  made 
use  of  in  the  text,  besides  which  he  is  familiar 
with  almost  all  that  has  been  written  in  Eng- 
lish and  German  on  the  above  topics. — Tfie 
Canada  Medical  Record. 

The  work  is  exceedingly  practical,  as  the 
chapters  on  the  treatment  of  the  various  con- 
ditions considered  are  based  on  sound  deduc- 
tions, are  complete,  and  easily  carried  out  by 
any  painstaking  surgeon.  All  in  all,  the  book 
is  a  most  excellent  one,  and  deserves  a  place  in 
every  well-selected  library. — Medical  Record. 

It  will  prove  exceedingly  valuable  in  the 
diffusion  of  more  thorough  knowledge  of  the 
subject-matter  among  English-speaking  sur- 
geons. As  in  the  case  of  all  his  work,  he  has 
done  this  in  a  truly  admirable  manner.  The 
book  throughout  is  worthy  of  the  highest 
praise.  It  should  be  adopted  as  a  text-book 
in  all  of  our  schools. —  University  Medical 
Magazine. 

The  principles  of  surgery,  as  expounded  by 
Dr.  Senn,  are  such  as  to  place  the  student  in 
the  independent  position  of  evolving  from 
them  methods  of  treatment ;  the  master  of  the 
principles  readilv  becomes  equally  a  master 
of  practice.  And  this,  of  course,  is  really  the 
whole  purpose  of  the  volume.—  Weekly  'Med- 
ical Review. 


HAY  FEVER 


S  A  JO  ITS 

And  Its  Successful  Treatment  toy  Superficial 

Organic  Alteration  of  the  Piasal 

Mucous  Membrane. 

By  CHARLES  E.  SAJOUS,  M.D.,  formerly  Lecturer  on  Rhinology  and  Laryngology  in 
Jefferson  Medical  College  ;  Cnief  Editor  of  the  Annual  of  the  Universal  Medical  Sciences, 
etc.  With  13  Engravings  on  Wood.  103  pages.  12mo.  Bound  in  Cloth,  Beveled  Edges. 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.00,  net ;  in  Great 
Britain,  6s. ;  in  France,  6  fr.  20. 

(20) 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 
SHOEMAKER 

Heredity,  Health,  and  Personal  Beauty. 

INCLUDING  THE  SELECTION  OF  THH  BEST  COSMETICS  FOR  THE  SKIN,  HAIR, 
NAILS,  AND  ALL  PARTS  RELATING  TO  THE  BODY. 

By  JOHN  V.  SHOEMAKER,  AM.,  M.D.,  Professor  of  Materia  Medica,  Phar- 
macology, Therapeutics,  and  Clinical  Medicine,  and  Clinical  Professor  of  Diseases 
of  the  Skin  in  the  Medico-Chirurgical  College  of  Philadelphia;  Physician  to  the 
Medico-Chirurgical  Hospital,  etc.,  etc. 

The  health  of  the  skin  and  hair,  and  how  to  promote  them,  are  discussed; 
the  treatment  of  the  nails;  the  subjects  of  ventilation,  food,  clothing,  warmth,' 
bathing;  the  circulation  of  the  blood,  digestion,  ventilation;  in  fact, "all  that  iii 
daily  life  conduces  to  the  well-being  of  the  body  and  refinement  is  duly  enlarged 
upon.  To  these  stores  of  popular  information  is  added  a  list  of  the  best  medicated 
soaps  and  toilet  soaps,  and  a  whole  chapter  of  the  work  is  devoted  to  household 
remedies.  The  work  is  largely  suggestive,  and  gives  wise  and  timely  advice  as 
to  when  a  physician  should  be  consulted.  This  is  just  the  book  to  place  on  the 
waiting -room  table  of  every  physician,  and  a  work  that  will  prove  utefal  in  the  hands 
«/  your  patients. 

Complete  in  one  handsome  Royal  Octavo  volume  of  425  pages,  beautifully 
and  clearly  printed,  and  bound  in  Extra  Cloth,  Beveled  Edges,  with  side  and 
back  gilt  stamps  and  in  Half-Morocco  Gilt  Top. 

Price,  in  United  States,  post-paid,  Cloth,  $2.50;  Half-Morocco,  $3.50, 
net.  Canada  (duty  paid),  Cloth,  $2.75;  Half-Morocco,  $3.90,  net. 
Great  Britain,  Cloth,  14s. ;  Half-Morocco,  19s.  6d.  France,  Cloth, 
15  fr.;  Half-Morocco,  22  fr. 

The  book  reads  not  like  the  fulfillment  of  a  \  pleased,  and  improved. — The  Southern  Clinic, 

task,  but  like  the  researches  and  observations  :  This  book  is  written  primarily  for  the  laity, 

of  one  thoroughly  in  love  with  his  subject,  jl  but  will  prove  of  interest  to  the  phvsician  as 

fully  appreciating  its  importance,  and  writing  !  well.  Though  the  author  goes  to  some  extent 

fur  the  pleasure  he  experiences  in  it.  The  i  into  technicalities,  he  confines  himself  to  the 

work  is  very  comprehensive  anil  complete  in  use  of  good,  plain  English,  and  in  that  respect 

its  scope.— Medical  World.  .i  sets  a  notable  example  to  many  other  writers 

The  book  before  us  is  a  most  remarkable   '!  on  similar  subjects.    Furthermore,  the  book 


production  and  a  most  entertaining  one.  The 
Uook  is  equally  well  adapted  for  ttie  laity  or 
the  profession.  It  tells  us  how  to  be  healthy, 
happy,  and  as  beautiful  as  possible.  We  can't 
review  this  book  ;  it  is  different  from  anythin 
we  have  ever  read.  It  runs  like  a  novel,  an 
will  be  perused  untU  finished  with  pleasure 
and  profit.  Buy  it,  read  it,  and  be  surprised, 


ng 
nd 


is  written  from  a  thoroughly  American  stand- 
point.— Medical  Record. 

This  is  an  exceedingly  interesting  book, 
both  scientific  and  practical  in  character,  in- 
tended for  both  professional  and  lay  readers. 
The  book  is  well  written  and  presented  in  ad- 
mirable formi  by  the  publisher. — Canadian 
Practitioner. 


SHOEMAKER 

Ointments  and  Oleates  :  E8pe" 


By  JOHN  V.  SHOEMAKER,  A.M.,  M.I).,  Professor  of  Materia  Medica,  Phar- 
macology, Therapeutics,  and  Clinical  Medicine,  and  Clinical  Professor  of  Diseases 
of  the  Skin  in  the  Medico-Chirurgical  College  of  Philadelphia,  etc.,  etc. 

The  author  concisely  concludes  his  preface  as  follows  :  "The  reader  may 
thus  obtain  a  conspectus  of  the  whole  subject  of  inunction  as  it  exists  to-day  in 
the  civilized  world.  In  all  cases  the  mode  of  preparation  is  given,  and  the  thera- 
peutical application  described  seriatim,  in  so  far  as  may  be  done  without  needless 
repetition." 

SECOND  EDITION,  revised  and  enlarged.  298  pages.  12mo.  Neatly  bound 
in  Dark-Blue  Cloth.  No.  6  in  the  Physicians'  and  Students'  Ready-Reference  Series. 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.50,  net  ;  in  Great 
Britain,  8s.  6i  ;  in  Prance,  9  fr.  35. 


It  is  invaluable  as  a  ready  reference  when 
ointments  or  oleates  are  to  be  used,  and  is 
serviceable  to  both  druggist  and  physician. — 
Canada  Medical  Record. 

To  the  physician  who  feels  uncertain  as  to 


the  best  form  in  which  to  prescribe  medicines 
by  way  of  the  skin  the  book  will  prove  valu- 
able, "owing  to  the  many  prescriptions  and 
formulae  which  dot  its  pages,  while  the  copious 
index  at  the  back  materially  aids  in  making 
the  book  a  useful  one.— Medical  News. 


(21) 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


Materia  Medica  and  Therapeutics. 

WITH  ESPECIAL  REFERENCE  TO  THE  CLINICAL  APPLICATION  OF  DRUGS. 
BEING  THE  SECOND  AND  LAST  VOLUME  OF  A  TREATISE  ON  MATERIA 
MEDICA,  PHARMACOLOGY,  AND  THERAPEUTICS,  AND  AN  INDEPENDENT 
VOLUME  UPON  DRUGS. 

By  JOHN  V.  SHOEMAKER,  A.M.,  M.D.,  Professor  of  Materia  Medica, 
Pharmacology,  Therapeutics,  and  Clinical  Medicine,  and  Clinical  Professor,  of 
Diseases  of  the  Skin  in  the  Medico-Chirurgical  College  of  Philadelphia;  Physician 
to  the  Medico-Chirurgical  Hospital,  etc.,  etc. 

This,  the  second  volume  of  Shoemaker's  "Materia  Medica,  Pharmacology, 
and  Therapeutics,"  is  wholly  taken  up  with  the  consideration  of  drugs,  each 
remedy  being  studied  from  three  points  of  view,  viz. :  the  Preparations,  or  Materia 
Medica;  the  Physiology  and  Toxicology,  or  Pharmacology;  and,  lastly,  its 
Therapy.  It  is  thoroughly  abreast  of  the  progress  of  Therapeutic  Science,  and 
is  really  an  indispensable  book  to  every  student  and  practitioner  of  medicine. 

Royal  Octavo,  about  675  pages.     Thoroughly  and  carefully  indexed. 

Price,  in  United  States,  post-paid,  Cloth,  $3.50;  Sheep,  $150,  net. 
Canada  (duty  paid),  Cloth,  $100;  Sheep,  $5.00,  net.  Great  Brit- 
ain, Cloth,  20s.;  Sheep,  26s.  France,  Cloth,  22  fr.  40;  Sheep, 
28  fr.  60. 

The  first  volume  of  this  work  is  devoted  to  Pharmacy,  General  Pharma- 
cology, and  Therapeutics,  and  remedial  agents  not  properly  classed  with  drugs. 
Royal  Octavo,  353  pages. 

Price  of  Volume  I,  post-paid,  in  United  States,  Cloth,  $2.50,  net;  Sheep, 
$3.25,  net.  Canada,  duty  paid,  Cloth,  $2.75,  net;  Sheep,  $3.60,  net. 
Great  Britain,  Cloth,  14s. ;  Sheep,  18s.  France,  Cloth,  16  fr.  ,°0 ; 
Sheep,  20  fr.  20.  The  volumes  are  sold  separately. 

SHOEMAKER'S  TREATISE  ON  MATERIA  MEDICA,  PHARMACOLOGY,  AND  THERA- 
PEUTICS STANDS  ALONE. 

(1)  Among  Materia  Medica  text-books,  in  that  it  includes  every  officinal  drug  and  every 

preparation  contained  in  the  United  States  Pharmacopoeia. 

(2)  In  that  it  is  the  only  work  on  therapeutics  giving  the  strength,  composition,  and  dosage 

of  every  officinal  preparation. 

(3)  In  giving  the  latest  investigations  with  regard  to  the  physiological  action  of  drugs  and 

the  most  recent  applications  in  therapeutics. 

(4)  In  combining  with  officinal  drugs  the  most  reliable  reports  of  the  actions  and  uses  of  all 

the  noteworthy  new  remedies,  such  as  acetanilid,  antipyrin,  bromoform,  exalgin.  pyok- 
tanin,  pyridin,  somnal,  spermine  (Brown-Sequard),  tuberculin  (Koch's lymph),  sulphonal, 
thiol,  urethan,  etc.,  etc. 

(5)  As  a  complete  encyclopaedia  of  modern  therapeutics  in  condensed  form,  arranged  alpha- 

betically for  convenience  of  reference  for  either  physician,  dentist,  or  pharmacist,  when 
immediate  information  is  wanted  concerning  the  action,  composition,  dose,  or  antidotes 
for  any  officinal  preparation  or  new  remedy. 

(6)  In  giving  the  physical  characters  and  chemical  formulae  of  the  new  remedies,  especially 

the  recently-introduced  antipyretics  and  analgesics. 

(7)  In  the  fact  that  it  gives  special  attention  to  the  consideration  of  the  diagnosis  and  treat- 

ment of  poisoning  by  the  more  active  drugs,  both  officinal  and  non-officinal. 

(8)  And  unrivaled  in  the  number  and  variety  of  the  proscriptions  and  practical  formulae, 

representing  the  latest  achievements  of  clinical  medicine. 

(9)  In  that,  while  summarizing  foreign  therapeutical  literature,  it  fully  recognizes  the  work 

done  in  this  department  by  American  physicians.  It  is  an  epitome  of  the  present  state 
of  American  medical  practice,  which  is  universally  acknowledged  to  be  the  best  practice. 

(10)  Because  it  is  the  most  complete,  convenient,  and  compendious  work  of  reference,  being, 

in  fact,  a  companion  to  the  United  States  Pharmacopoeia,  a  drug-encyclopaedia,  and  a 
therapeutic  hand-book  all  in  one  volume. 


The  value  of  the  book  lies  in  the  fact  that 
it  contains  all  that  is  authentic  and  trust- 
worthy about  the  host  of  new  remedies  which 
have  deluged  us  in  the  last  five  years.  The 
pages  are  remarkably  free  from  useless  infor- 
mation. The  author  has  done  well  in  following 
the  alphabetical  order.— N.  Y.  Med.  Record. 

In  perusing  the  pages  devoted  to  the  special 
consideration  of  drugs,  their  pharmacology, 
physiological  action,  toxic  action,  and  therapy, 
one  is  constantly  surprised  at  the  amount  of 

(22) 


material  compressed  in  so  limited  a  space. 
The  book  will  prove  a  valuable  addition  to  the 
physician  's  library. — Occidental  Med.  Times. 
It  is  a  meritorious  work,  with  many  unique 
features.  It  is  richly  illustrated  by  well-tried 
prescriptions  showing  the  practical  applica- 
tion of  the  various  drugs  discussed.  In  short, 
this  work  makes  a  pretty  complete  encyclo- 
paedia of  the  science  of  therapeutics,  conve- 
niently arranged  for  handy  reference.—  Med. 
World. 


Medical  Publications  of  The  F.  A.  Davis  (7o.,  Philadelphia. 


SMITH 

Physiology  of  the  Domestic  Animals. 

A  TEXT-BOOK  FOR  VETERINARY  AND  MEDICAL  STUDENTS  AND  PRACTITIONERS. 

By  ROBERT  MEADE  SMITH,  A.M.,  M.D  ,  Professor  of  Comparative  Physi- 
ology in  University  of  Pennsylvania;  Fellow  of  the  College  of  Physicians  and 
Academy  of  the  Natural  Sciences,  Philadelphia;  of  American  Physiological 
Society;  of  the  American  Society  of  Naturalists,  etc. 

This  new  and  important  work,  the  most  thoroughly  complete  in  the 
English  language  on  this  subject,  treats  of  the  physiology  of  the  domestic  animals 
in  a  most  comprehensive  manner,  especial  prominence  being  given  to  the  subject 
of  loods  and  fodders,  and  the  character  of  the  diet  for  the  herbivora  under 
different  conditions,  with  a  full  consideration  of  their  digestive  peculiarities. 
Without  being  overburdened  with  details,  it  forms  a  complete  text-book  of 
physiology  adapted  to  the  use  of  students  and  practitioners  of  both  veterinary 
and  human  medicine.  This  work  has  already  been  adopted  as  the  Text-Book  on 
Physiology  in  the  Veterinary  Colleges  of  the  United  States,  Great  Britain,  and 
Canada.  In  one  Handsome  Royal  Octavo  Volume  of  over  950  pages,  profusely 
illustrated  with  more  than  400  Fine  Wood-Engravings  and  many  Colored  Plates. 

United  States.       Canada  (duty  paid)    Great  Britain.        France. 

Price,  Cloth,      -    -    $5.00,  Net         $5.50,  Net  28s.        30  fr.  30 

41     Sheep,    -    -     6.00    "  6.60    "  32s.         36  fr.  20 

full  understanding  of  the  text.— Journal  of 
Comparative  Medicine  and  Surgery. 

Veterinary  practitioners  and  graduates  will 
read  it  with  pleasure.  Veterinary  students 
will  readily  acquire  needed  knowledge  from 
its  pages,  and  veterinary  schools,  which  would 
be  well  equipped  for  the  work  they  aim  to 
perform,  cannot  ignore  it  as  their  text-book 
in  physiology.— American  Veterinary  Review. 

Altogether,  Professor  Smith's  "Physiology 
of  the  Domestic  Aninials"  is  a  happy  produc- 
tion, and  will  be  hailed  with  delight  in  both 
the  human  medical  and  veterinary  medical 
worlds.  It  should  find  its  place,  besides,  in  all 
agricultural  libraries.— PAUL  PAQUIN,  M.D., 
V.B.,  in  the  Weekly  Medical  Review. 

The  author  has  Judiciously  made  the  nutri- 
tive functions  the  strong  point  of  the  work, 
and  has  devoted  special  attention  to  the  sub- 
ject of  foods  and  digestion.  In  looking 
through  other  sections  of  the  work,  it  appears 
to  us  that  a  just  proportion  of  space  is  assigned 
to  each,  in  view  of  their  relative  importance 
to  the  practitioner. — London  Lancet. 


A.  LIAUTARD,  M.D.,  H.F.R.C.,  V.S.,  Pro- 
fessor of  Anatomy,  Operative  Surgery,  and 
Sanitary  Medicine  in  the  American  V  eterinary 
College,  New  York,  writes: — "I  have  exam- 
ined the  work  of  Dr.  R.  M.  Smith  on  the 
'Physiology  of  the  Domestic  Animals,'  and  con- 
sider it  one  of  the  best  additions  to  veterinary 
literature  that  we  have  had  for  some  time." 

E.  M.  READING,  A.M.,  M.D.,  Professor  of 
Physiology  in  the  Chicago  Veterinary  College, 
writes: — "I  have  carefully  examined  the 
'Smith's  Physiology,'  published  by  you,  and 
like  it.  It  is  comprehensive,  exhaustive,  and 
complete,  and  is  especially  adapted  to  those 
who  desire  to  obtain  a  full  knowledge  of  the 
principles  of  physiology,  and  are  not  satisfied 
with  a  mere  smattering  of  the  cardinal  points." 

Dr.  Smith's  presentment  of  his  subject  is  as 
brief  as  the  status  of  the  science  permits,  and 
to  this  much-desired  conciseness  he  has  added 
an  equally  welcome  clearness  of  statement. 
The  illustrations  in  the  work  are  exceedingly 
good,  and  must  prove  a  valuable  aid  to  the 


SOZINSKEY 


Medical  Symbolism. 


Historical  Studies  in  the  Arts 
of  Healing  and  Hygiene. 

By  THOMAS  S.  SOZINSKEY,  M.D.,  PH.D.,  Author  of  "The  Culture  of 
Beauty,"  "The  Care  and  Culture  of  Children,"  etc. 

12mo.  Nearly  200  pages.  Neatly  bound  in  Dark-Blue  Cloth.  Appropri- 
ately illustrated  with  upward  of  thirty  (30)  new  Wood-Engravings.  No.  9  in  the 
Physicians'  and  Students'  Ready-Reference  Series. 

Price,  post-paid,  in  United  States  and  Canada,  $1.00,  net;  Great 
Britain,  6s. ;  France,  6  fr.  20. 

will  value  as  sound  and  serious  matter." — Can- 
adian Practitioner. 

In  the  volume  before  us  we  have  an  admira- 
ble and  successful  attempt  to  set  forth  in 
order  those  medical  symbols  which  have  come 
down  to  us,  and  to  explain  on  historical  grounds 
their  significance.  An  astonishing  amount  of 
information  is  contained  within  the  covers  of 
the  book,  and  every  page  of  the  work  bears 
token  of  the  painstaking  genius  and  erudite 
mind  of  the  now  unhappily  deceased  author. 
— London  Lancet. 


He  who  has  not  time  to  more  fully  study  the 
more  extended  records  of  the  past,  will  highly 
prize  this  little  book.  Its  interesting  discourse 
upon  the  past  is  full  of  suggestive  thought. — 
American  Lancet. 

Like  an  oasis  in  a  dry  and  dusty  desert  of 
medical  literature,  through  which  we  wearily 
stagger,  is  this  work  devoted  to  medical  sym- 
bolism and  mythology.  As  the  author  aptly 
quotes:  "What  some  light  braines  may  esteem 
as  foolish  toyes,  deeper  judgments  can  and 


'23) 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


STEWART 


Obstetric  Synopsis. 


By  JOHN  S.  STEWART,  M.D.,  formerly  Demonstrator  of  Obstetrics  and 
Chief  Assistant  in  the  Gynaecological  Clinic  of  the  Merlico-Chirnrgical  College 
of  Philadelphia:  with  an  introductory  note  by  WILLIAM  S.  STEWART,  A.M., 
M.D.,  Professor  of  Obstetrics  and  Gynaecology  in  the  Medico-Chirurgical  College 
of  Philadelphia. 

By  students  this  work  will  be  found  particularly  useful.  It  is  based  upon 
the  teachings  of  such  well-known  authors  as  Playfair,  Parvin,  Lusk,  Galabiii, 
and  Cazeaux  and  Tarnier,  and  contains  much  new  and  important  matter  of  great 
value  to  both  student  and  practitioner. 

With  42  Illustrations.  202  pages.  12mo.  Handsomely  bound  in  Dark- 
Blue  Cloth.  No.  1  in  the  Physicians'  and  Students'  Ready -Reference  Series. 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.00,  net ;  in  Great 
Britain,  6s.;  France,  6  fr.  20. 

DEL.ASKIE  MILLER,  M.D.,  Professor  of 
Obstetrics,  Rush  Medical  College,  Chicago, 
III.,  says: — "I  have  examined  the  'Obstetric 
Synopsis,'  by  John  S.  Stewart,  M.D.,  and  it 
gives  me  pleasure  to  characterize  the  work  as 
systematic,  concise,  perspicuous,  and  authen- 
tic. Among  manuals  it  is  one  of  the  best." 

It  is  well  written,  excellently  illustrated, 
and  fully  up  to  date  in  every  respect.  Here 
we  find  all  the  essentials  of  Obstetrics  in  a 
nutshell,  Anatomy,  Embryology,  Physiology, 
Pregnancy,  Labor,  Puerperal  State,  and  Ob- 
stetric Operations  all  being  carefully  and  ac- 


curately described. — Buffalo  Medical  and 
Surgical  Journal. 

It  is  clear  and  concise.  The  chapter  on  the 
development  of  the  ovum  is  especially  satis- 
factory. The  judicious  use  of  bold-faced 
type  for  headings  and  italics  for  iniportant 
statements  gives  the  book  a  pleasing  typo- 
graphical appearance. — Medical  Record. 

Tnis  volume  is  done  with  a  masterly  hand. 
The  scheme  is  an  excellent  one.  The  whole 
is  freely  and  most  admirably  illustrated  with 
well-drawn,  new  engravings,  and  the  book  is 
of  a  very  convenient  size. — St.  Louis  Medical 
and  Surgical  Journal. 


ULTZMANN 

The  Neuroses  of  the  Genito-Urinary  System 

in  the  Male. 

WITH  STERILITY  AND  IMPOTENCE. 

By  DR.  R.  ULTZMANN,  Professor  of  Genito-Urinary  Diseases  in  the  Uni- 
versity of  Vienna.  Translated,  with  the  author's  permission,  by  GARDNER  W. 
ALLEN,  M.D.,  Surgeon  in  the  Genito-Urinary  Department,  Boston  Dispensary. 

.Full  and  complete,  yet  terse  and  concise,  it  handles  the  subject  with  such 
a  vigor  of  touch,  such  a  clearness  of  detail  and  description,  and  such  a  directness 
to  the  result,  that  no  medical  man  who  once  takes  it  up  will  be  content  to  lay  it 
down  until  its  perusal  is  complete, — nor  will  one  reading  be  enough. 

Professor  Ultzmann  has  approached  the  subject  from  a  somewhat  differe.,t 
point  of  view  from  most  surgeons,  and  this  gives  a  peculiar  value  to  the  work. 
It  is  believed,  moreover,  that  there  is  no  convenient  hand-book  in  English  treat- 
ing in  a  broad  manner  the  Genito-Urinary  Neuroses. 

SYNOPSIS  OF  CONTENTS.  —First  Part — I.  Chemical  Changes  in  the  Urine  in 
Cases  of  Neuroses.  II.  Neuroses  of  the  Urinary  and  of  the  Sexual  Organs, 
classified  as  :  (1)  Sensory  Neuroses;  (2)  Motor  Neuroses  ;  (3)  Secretory  Neuroses. 
Second  Part — Sterility  and  Impotence.  The  treatment  in  all  cases  is  described 
clearly  and  minutely. 

Illustrated.  12mo.  Handsomely  bound  in  Dark-Blue  Cloth.  No.  4  in  the 
Physicians'  and  Students'  Ready -Reference  Series. 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.00,  net ;  in  Great 
Britain,  6s. ;  in  France,  6  fr.  20. 

This  book  is  to  be  highly  recommended, 
owi  ng  to  its  clearness  and  brevi  tv.  Altogether, 
we  do  not  know  of  any  book  of  the  same  size 
which  contains  so  much  useful  information  in 
such  a  short  space.— Medical  News. 

Its  scope  is  large,  not  being  confined  to  the 
one  condition, — neurasthenia, — but  embracing 
all  of  the  neuroses,  motor  and  sensory,  of  the 
genito-urinary  organs  in  the  male.  No  one 
who  has  read  after  Dr.  Ultzmann  need  be  re- 


minded of  lite  delightful  manner  of  presenting 
his  thoughts,  which  ever  sparkle  with  original- 
ity and  appositeness.—  Weekly  Med.  Review. 

It  engenders  sound  pathological  teaching, 
and  will  aid  in  no  small  degree  in  throwing 
light  on  the  management  of  many  of  the  dif- 
ficult and  more  refractory  cases  of  the  clas.ses 
to  which  these  essays  especially  refer.— The 
Medical  Age. 


(24) 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


SANNE 

Diphtheria,  Croup:    Tracheotomy  and 
Intubation. 

FROM  THE  FRENCH  OF  A.  SANNE. 

Translated  and  enlarged  by  HESTBY  Z.  GILL,  M.D.,  LL.D.,  Late  Professor  of  Surgery 
In  Cleveland,  Ohio. 

Sanue's  work  is  quoted,  directly  or  indirectly,  by  every  writer  since  its  publication, 
as  the  highest  authority,  statistically,  theoretically,  and  practically.  The  translator,  having 
given  special  study  to  the  subject  for  many  years,  has  added  over  fifty  pages,  including  the 
Surgical  Anatomy,  Intubation,  and  the  recent  progress  in  other  branches,  making  it, 
beyond  question,  the  most  complete  work  extant  on  the  subject  of  Diphtheria  in  the 
English  language. 

Facing  the  title-page  is  found  a  very  fine  Colored  Lithograph  Plate  of  the  partejfcon- 
cerned  in  Tracheotomy.  Next  follows  an  illustration  of  a  cast  of  the  entire  Trachea*  and 
Bronchi  to  the  third  or  fourth  division,  in  one  piece,  taken  from  a  photograph  of  a  case  in 
which  the  cast  was  expelled  during  life  from  a  patient  sixteen  years  old.  This  is  the  most 
complete  cast  of  any  one  recorded. 

Over  fifty  other  illustrations  of  the  surgical  anatomy  of  instruments,  etc.,  add  to  the 
practical  value  of  the  work. 

A  full  Index  accompanies  the  enlarged  volume,  also  a  List  of  Authors,  making 
altogether  a  very  handsome  illustrated  octavo  volume  of  over  680  pages. 

United  States.    Canada  (duty  paid) .    Great  Britain.  France. 

Price,  post-paid,  Cloth,  $100,  Net        $140,  Net         22s.  6d.        24  fr.  60 

Leather,         5.00    "  5.50    "  28s.  30  fr.  30 


YOUNG 


BEING  A  COMPLETE  COMPEND  OF  ANATOMY,  INCLUDING  THE  ANATOMY  OF 
THE  VISCERA,  AND  NUMEROUS  TABLES. 

By  JAMES  K.  YOUNG,  M.D.,  Instructor  in  Orthopaedic  Surgery  and  Assistant  Demon- 
strator of  Surgery,  University  of  Pennsylvania;  Attending  Orthopaedic  Surgeon,  Out- 
Patient  Department,  University  Hospital,  etc. 

While  the  author  has  prepared  this  work  especially  for  students,  sufficient  descriptive 
matter  has  been  added  to  render  it  extremely  valuable  to  the  busy  practitioner,  particularly 
the  sections  on  the  Viscera,  Special  Senses,  and  Surgical  Anatomy. 

The  work  includes  a  complete  account  of  Osteology,  Articulations  and  Lisramente, 
Muscles,  Fascias,  Vascular  and  Nervous  Systems,  Alimentary,  Vocal,  and  Respiratory  and 
Geuito-Uriuary  Apparatus,  the  Organs  of  Special  Sense,  and  Surgical  Anatomy. 

In  addition  to  a  most  carefully  and  accurately  prepared  text,  wherever  possible,  the 
value  of  the  work  has  been  enhanced  by  tables  to  facilitate  aud  minimize  the  labor  of  stu- 
dents in  acquiring  a  thorough  knowledge  of  this  important  subject.  The  section  on  the 
teeth  has  also  been  especially  prepared  to  meet  the  requirements  of  students  of  dentistry. 

Illustrated  with  76  Wood-Engravings.  390  pages.  12mo.  Bound  in  Extra  Dark- 
Blue  Cloth.  No.  S  in  the  Physicians'  and  Students'  Ready-Reference  Series. 

Price,  post-paid,  in  the  United  States  and  Canada,  $1.40,  net;  in  Great 
Britain,  8s.  6d  ;  in  France,  9  fr.  25. 


Every  unnecessary  word  has  been  excluded, 
out  of  regard  to  the  very  limited  time  at  the 
medical  student's  disposal.  It  is  also  good  as 


has  a  definite  field  of  usefulness.— Pittsburgh 
Medical  Review. 
The  book  is  much  more  satisfactory  than  the 


a  reference-book,  as  it  presents  the  facts  about  j     " remembrances'' in  vogue,  and  yet  is  not  too 
which  he  wishes  to  refresh  his  memory  in  the        cumbersome  to  be  carried  around  and  read  at 

odd  moments— a  property  which  the  student 


briefest  manner  consistent  with  clearness. — 
New  York  Medical  Journal. 

As  a  companion  to  the  dissecting-table,  and 
a  convenient  reference  for  the  practitioner,  it 

(25) 


will    readily    appreciate.  —  Weekly    Medical 
Review. 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


WITHERSTINE 

The  International  Pocket  Medical  Formulary 

ARRANGED  THERAPEUTICALLY. 

By  C.  SUMNER  WITHERSTINE,  M.S.,  M.D.,  Associate  Editor  of  the 
"Annual  of  the  Universal  Medical  Sciences  ;"  Visiting  Physician  of  the  Home 
for  the  Aged,  Gennantown,  Philadelphia  ;  Late  House-Surgeon  Charity  Hospital, 
New  York. 

More  than  1800  formulae  from  several  hundred  well-known  authorities. 
With  an  Appendix  containing  a  Posological  Tahle,  the  newer  remedies  included  ; 
Important  Incompatibles  ;  Tables  on  Dentition  and  the  Pulse  ;  Table  of  Drops 
in  a  Fluidrachm  and  Doses  of  Laudanum  graduated  for  age  ;  Formulae  and. Doses 
of  Hypodermatic  Medication,  including  the  newer  remedies  ;  Uses  of  the  Hypo- 
dermatic Syringe  ;  Formulae  and  Doses  for  Inhalations,  Nasal  Douches,  Gargles, 
and  Eye-washes  ;  Formulae  for  Suppositories  ;  Use  of  the  Thermometer  in  Dis- 
ease ;  Poisons,  Antidotes,  and  Treatment ;  Directions  for  Post-Mortem  and 
Medico-Legal  Examinations  ;  Treatment  of  Asphyxia,  Sun-stroke,  etc.  ;  Anti- 
emetic  Remedies  and  Disinfectants  ;  Obstetrical  Table  ;  Directions  for  Ligations 
of  Arteries  ;  Urinary  Analysis  ;  Table  of  Eruptive  Fevers  ;  Motor  Points  for 
Electrical  Treatment,  etc. 

This  work,  the  best  and  most  complete  of  its  kind,  contains  about  275 
printed  pages,  besides  extra  blank  leaves — the  book  being  interleaved  throughout 
— elegantly  printed,  with  red  lines,  edges,  and  borders;  with  illustrations.  Bound 
in  leather,  with  side  flap. 

It  is  a  handy  book  of  reference,  replete  with  the  choicest  formulas  (over 
1800  in  number)  of'more  than  six  hundred  of  the  most  prominent  classical  writers 
and  modern  practitioners. 

The  remedies  given  are  not  only  those  whose  efficiency  has  stood  the  test 
of  time,  but  also  the  newest  and  latest  discoveries  in  pharmacy  and  medical 
science,  as  prescribed  and  used  by  the  best-known  American  and  foreign  modern 
authorities. 

It  contains  the  latest,  largest  (66  formulae),  and  most  complete  collection  of 
hypodermatic  formulae  (including  the  latest  new  remedies)  ever  published,  with 
doses  and  directions  for  their  use  in  over  fifty  different  diseases  and  diseased 
conditions. 

Its  appendix  is  brimful  of  information,  invaluable  in  office  work,  emergency 
cases,  and  the  daily  routine  of  practice. 

It  is  a  reliable  friend  to  consult  when,  in  a  perplexing  or  obstinate  case,  the 
usual  line  of  treatment  is  of  no  avail.  (A  hint  or  a  help  from  the  best  authorities, 
as  to  choice  of  remedies,  correct  dosage,  and  the  eligible,  elegant,  and  most  palat- 
able mode  of  exhibition  of  the  same.) 

It  is  compact,  elegantly  printed  and  bound,  well  illustrated,  and  of  conve- 
nient size  and  shape  for  the  pocket. 

The  alphabetical  arrangement  of  the  diseases  and  a  thumb-letter  index 
render  reference  rapid  and  easy. 

Blank  leaves,  judiciously  distributed  throughout  the  book,  afford  a  place  to 
record  and  index  favorite  formulae. 

As  a  student,  the  physician  needs  it  for  study,  collateral  reading,  and  for 
recording  the  favorite  prescriptions  of  his  professors,  in  lecture  and  clinic;  as  a 
recent  graduate,  he  needs  it  as  a  reference  hand-book  for  daily  use  in  prescribing 
(gargles,  nasal  douches,  inhalations,  eye-washes,  suppositories,  incompatibles, 
poieons,  etc.);  as  an  old  practitioner,  he  needs  it  to  refresh  his  memory  on  old 
remedies  and  combinations,  and  for  information  concerning  newer  remedies  and 
more  modern  approved  plans  of  treatment. 

No  live,  progressive  medical  man  can  afford  to  be  without  it. 

Price,  post-paid,  in  United  States  and  Canada  $2.00,  net ; 
Great  Britain,  lls.  6d. ;  France,  12  fr.  40. 


It  is  sometimes  important  that  such  prescrip- 
tions as  have  been  well  established  in  their 
usefulness  be  preserved  for  reference,  and 
this  little  volume  serves  such  a  purpose  better 
than  any  other  we  have  seen. — Columbus  Med- 
ical Journal. 

To  the  young  physiciun  just  starting  out  in 
practice  this  little  book  will  prove  an  accept- 
able companion. — Omaha  Clinic. 

As  long  as  "combinations"  are  sought,  such 
a  book  will  be  of  value,  especially  to  those 
who  cannot  spare  the  time  required  to  learn 


enough  of  incompatibilities  before  commenc- 
ing practice  to  avoid  writing  incompatible  and 
dangerous  prescriptions.  The  constant  use  of 
such  a  book  by  such  prescribers  would  save 
the  pharmacist  much  anxiety. — The  Drug- 
gists' Circular. 

In  judicious  selection,  in  accurate  nomen- 
clature, in  arrangement,  and  in  style,  it  leaves 
nothing  to  be  desired.  The  editor  and  the 
publisher  are  to  be  congratulated  on  the  p re- 
duction of  the  very  best  book  of  its  class. — 
Pittsburgh  Medical  Review. 


(26) 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


Annual  of  the  Universal  Medical  Sciences. 

A  YEARLY  REPORT  OF  THE  PROGRESS  OF  THE  GENERAL  SANITARY 
SCIENCES  THROUGHOUT  THE  WORLD. 

Edited  by  CHARLES  E.  SAJOUS,  M.D.,  formerly  Lecturer  on  Laryngology 
and  Rhinology  in  Jefferson  Medical  College,  Philadelphia,  etc.,  and  Seventy 
Associate  Editors,  assisted  by  over  Two  Hundred  Corresponding  Editors  and 
Collaborators.  In  Five  Royal  Octavo  Volumes  of  about  500  pages  each,  bound 
in  Cloth  and  Half-Russia,  Magnificently  Illustrated  with  Chromo-Lithographs, 
Engravings,  Maps,  Charts,  and  Diargrams.  Being  intended  to  enable  any  physi- 
cian to  possess,  at  a  moderate  cost,  a  complete  Contemporary  History  of  Universal 
Medicine,  edited  by  many  of  America's  ablest  teachers,  and  superior  in  every 
detail  of  print,  paper,  binding,  etc.,  a  befitting  continuation  of  such  great  works 
as  "Pepper's  System  6f  Medicine,"  "Ashhurst's  International  Encyclopaedia  of 
Surgery,"  "Buck's  Reference  Hand-Book  of  the  Medical  Sciences." 

SOLD  ONLY  BY  SUBSCRIPTION,  OR  SENT  DIRECT  ON  RECEIPT  OF  PRICE, 
SHIPPING  EXPENSES  PREPAID. 

Subscription  Price  per  Year  (including  the  "  SATELLITE  "  for  one  year) : 
In  United  States,  Cloth,  5  vols.,  Eoyal  Octavo,  $15.00;  Half-Eussia,  5  vols., 
Boyal  Octavo,  $20.00.  Canada  (duty  paid),  Cloth,  $16  50 ;  Half-Eussia, 
$22.00.  Great  Britain,  Cloth,  £4  7s. ;  Half-Eussia,  £5  15s.  France,  Cloth, 
93  fr.  95 ;  Half-Eussia,  124  fr.  35. 

THE  SATELLITE  of  the  "Annual  of  the  Universal  Medical  Sciences."  A 
Monthly  Review  of  the  most  important  articles  upon  the  practical  branches  of 
Medicine  appearing  in  the  medical  press  at  large,  edited  by  the  Chief  Editor  of 
the  ANNUAL  and  an  able  staff.  Published  in  connection  with  the  ANNUAL,  and 
for  its  Subscribers  Only. 


Editorial  Staff  of  the  Annual  of  the  Universal  Medical  Sciences. 

CONTRIBUTORS  TO  SERIES  1888,  1889,  1890,  1891. 

EDITOB-IN-CHIEF,  CHARLES  E.  SAJOUS,  M.D.,  PHILADELPHIA. 


SENIOR  ASSOCIATE    EDITORS. 

Agnew,  D.  Haves,  M.D.,  LL.D.,  Philadelphia, 

series  of  1888,  1889. 

Baldy,  J.  M..  M.D.,  Philadelphia,  1891. 
Barton,  J.  M.,  A.M.,  M.D.,  Philadelphia,  1889, 

1X90,  1891. 
Birdsall,  W.  R.,  M.D.,  New  York,  1889,  1890, 

1891. 

Brown,  F.  W.,  M.D.,  Detroit,  1890,  1891. 
Bruen,  Edward  T.,  M.D.,  Philadelphia,  1889. 
Brush,  Edward  N.,   M.D.,  Philadelphia,  1889, 

1890.  1891. 
Cohen.  J.  Holis,  M.D.,  Philadelphia,   1888,  1889, 

1890,  1891. 
Conner,  P.  S.,  M.D.,  LL.D.,  Cincinnati,  1888, 

1889,  1890,  1891. 

Currier,  A.  F.,  A.B.,  M.D.,  New  York,   1889, 

1890,  1891. 

Davidson,  C.  C.,  M  D.,  Philadelphia.  1888. 
Davis,  N.  S.,  A.M.,  M.D.,  LL.D.,  Chicago,  1888, 

1889,  1890.  1891. 

Delafleld,  Francis,  M.D.,  New  York.  1888. 
Delavan,  D.  Brvson.  M.D.,   New  York,  1888, 

1889,1890,1891. 
Draper,  F.  Winthrop,  A.M.,  M.D.,  New  York, 

1888,  1889.  1890.  1891. 

Dudley,  Edward  C.,  M.D.,  Chicago,  1888. 
Ernst.  Harold  C.,   A.M.,  M.D.,  Boston,  1889, 

1890,  1891. 

Forbes,  William  S.,  M.D.,  Philadelphia,  1888, 

1889,  1890. 

Garretson,    J.   E.,   M.D..    Philadelphia,    1888, 


Gaston,  J.   McFadden,  M.D.,    Atlanta,    1890, 

1891. 
Gihon,  Albert  "L.,  A.M.,  M.D.,  Brooklyn,  1888, 

1889,  1890.  1891. 
Goodell,  William,   M.D.,    Philadelphia,    1888, 

1889,  1890. 

Grav.  Landon  Carter,  M.D.,  NewYork,  1890, 

1891. 
Griffith,  J.  P.  Crozer,  M.D.,  Philadelphia,  1889, 

1890. 1891. 
Guilford,  S.  H.,  D.D.S.,  Ph.D.,  Philadelphia, 

1888. 
Guiteras,  John,  M.D.,  Ph,D.,  Charleston,  1888, 

1889. 
Hamilton.  John  B..  M.D.,  LL.D.,  Washington, 

1888.  1889,  1890.  1891. 

Hare.  Hobart  Amorv.  M.D.,  B.Sc.,  Philadel- 
phia. 1888.  1889.  1890,  1891. 
Henry.  Frederick  P.,  M.D.,  Philadelphia,  1889, 

1890,  1891. 

Holland,  J.  W.,  M.D.,  Philadelphia,  1888.  1889. 
Holt    L.  Emmett,  M.D.,  New  York,  1889,  1890, 

1891. 
Howell.   W.    H..    Ph.D.,  M.D.,   Ann    Arbor, 

1889.  1890,  1891. 

Hun.  Henry,  M.D..  Albany,  1889.  1890. 
Hooper.  Franklin  H.,  M.D'..  Boston,  1890.  1891. 
Ingals.  E.  Fletcher,  A.M.,  M.D.,  Chicago,  1889, 

1890.  1891. 

Jaggard,  W.  W.,  A.M.,  M.D.,  Chicago.  1890. 
Johnston,  Christopher,  M.D.,  Baltimore,  1888, 

1889. 
Johnston,  W.  W.,  M.D.,  Washington,  1888, 1889, 

1890,  i891. 


(27) 


Medical  Publications  of  The  F.  A,  Dam's  (7o.,  Philadelphia. 


SENIOR   ASSOCIATE    EDITORS 

(CONTINUED). 

Keating,  John  M.,  M.D.,  Philadelphia,  1889. 
Kelsev,  Charles  B.,  M.D.,  New  York,  1888, 1889, 

1890,  1891. 
Iveyes,   Kclward  L.,  A.M..  M.D.,  New  York, 

1888,  1889,  1890,  1891. 

Knapp,  Philip  Coombs.  M.D.,  Boston,  1891. 
Laplace,    Ernest,   A.M.,   M.D.,   Philadelphia, 

1890.  1891. 

Lee,  John  G.,  M.D.,  Philadelphia,  1888. 
Leidy,  Joseph,  M.D.,  LL.D.,  Philadelphia,  1888, 

1889,  1890,  1891. 

Longstreth,  Morris,  M.D.,  Philadelphia,  1888, 

1889,  1890. 

Loomis,  Alfred  L.,  M.D.,   LL.D.,  New  York, 

1888,  1889. 

Lynian,  Henry  M.,  A.M.,  M.D.,  Chicago,  1888. 
McGuire,  Hunter,  M.D.,   LL.D.,   Richmond, 

1888. 
Manton,  Walter  P.,  M.D.,  F.R.M.S.,  Detroit, 

1888,1889.  1890,  1891. 
Martin,  H.  Newell.  M.D.,  M.A.,  Dr.  Sc.,  F.R.S., 

Baltimore,  1888, 1889. 
Matas,  Rudolph,    M.D.,  New    Orleans,    1890, 

1891. 
Mears,  J.  Ewing,  M.D.,  Philadelphia,  1888, 1889, 

1890,  1891. 

Mills,  Charles  K.,  M.D.,  Philadelphia,  1888. 
Minot,   Clias.   Sedgwick,  M.D.,  Boston,  1888, 

1889,  1890,  1891. 

Montgomery,  E.  E.,  M.D.,  Philadelphia,  1891. 
Morton,  Thos.  G.,   M.D..   Philadelphia.  1888, 

1889. 
Munde,  Paul  F.,  M.D.,  New  York,  1888,   1889, 

1890,  1891. 

Oliver,  Charles  A.,  A.M.,  M.D.,  Philadelphia, 

1889,  1890,  1891. 
Packard,  John  H.,  A.M.,  M.D.,  Philadelphia, 

1888,  1889,  1890,  1891. 

Parish,  Wm.H.,  M.D.,  Philadelphia,  1888, 1889, 
1890. 

Parvin,  Theophilus,  M.D.,  LL.D.,  Philadel- 
phia, 1888,  1889. 

Pierce,  C.  N.,  D.D.S.,  Philadelphia,  1888. 

Pepper,  William,  M.D.,  LL.D.,  Philadelphia, 
1888. 

Ranney,  Ambrose  L.,  M.D.,  New  York,  1888, 

1889,  1890. 

Richardson,  W.  L.,  M.D.,Boston,  1888,  1889. 
Rockwell,  A.  D.,  A.M.,  M.D.,  New  York,  1891. 
Rohe,  Geo.  H.,  M.D.,  Baltimore.  1888, 1889, 1890, 

1891. 
Sajous,  Chas.  E.,  M.D.,  Philadelphia.  1888, 1889, 

1890, 1891. 

Sayre,  Lewis  A..M.D.,  New  York,  1890,  1891. 
Seguin,  E.  C.,  M.D.,    Providence,   1888,  1889, 

1890,  1891. 

Senn,  Nicholas,  M.D.,  Ph.D.,  Milwaukee,  1888, 

1889. 

Shakspeare,  E.  Q.,  M.D.,  Philadelphia,  1888. 
Shattuck,  F.  C.,  M.D.,  Boston,  1890. 
Smith,  Allen  J.,  A.M.,  M.D.,  Philadelphia,  1890, 

1891. 
Smith,  J.  Lewis,  M.D.,  New  York,  1888,  1889, 

1890,  1891. 

Spitzka,  K.  C.,  M.D.,  New  York.  1888. 
Starr,   Louis,   M.D.,   Philadelphia,  1888,  1889, 

1890.  1891. 
Stimson.  Lewis  A.,  M.D.,  New  York,  1888,  1889, 

1890,  1891. 

Siurgis,  F.  R.,  M  D.,  New  York,  1888. 
Sudduth,  F.  X.,  A.M..  M.D..  F.R.M.S.,  Minne- 
apolis, 1888,  1889,  1890,  1891. 
Thomson,  William,  M.D.,  Philadelphia,  1888. 
Thomson,  Wm.  H.,  M.D.,  New  York,  1888. 
Tiffany.  L.  McLane,  A.M.,  M.D.,  Baltimore, 

1890,  1891. 
Turnlwill.  Chas.  S.,  M.D.,  Ph.D.,  Philadelphia, 

1888,  1889,  1890  1891. 
Tyson,  James,  M.D.,  Philadelphia,  1888,  1889, 

1890. 
Van  Harlingen,  Arthur,  M.D.,  Philadelphia, 

1888,  1*89,  1890, 1891. 
Vander  Veer,  Albert,  M.D.,  Ph.D.,  Albany, 

1890. 
Whittaker,  .las.  T.,  M.D.,  Cincinnati,  1888, 1889, 

1890, 1891. 

Whittier.  E.  N.,  M.D.,  Boston,  1890,  1891. 
Wilson,  James  C.,  A.M.,   M.D.,  Philadelphia, 

1888. 1889.  1890,  1891. 


Wirgman,  Chas.,  M.D.,  Philadelphia,  1888. 

Witherstine,  C.  Sumner,  M.3.,  M.D.,  Phila- 
delphia, 18N«,  1889,  1S90,  1891. 

White,  J.  William,  M.D.,  Philadelphia,  1889, 
1890,  1891. 

Young,  Jas.  K.,  M.D.,  Philadelphia,  1891. 

JUNIOR   ASSOCIATE    EDITORS. 

Baldy,  J.  M.,  M.D.,  Philadelphia,  1890. 

Bliss.  Arthur  Ames,  A.  M.,  M.D.,  Philadelphia, 
1890,  1891. 

Cattell,  H.  W.,  M.D..  Philadelphia,  1890,  1891. 

Cerna,  David,  M.D.,  PhD..  Philadelphia,  Ib91. 

Clark,  J.  Payson,  M.D.,  Boston,  1890.  1891. 

Crandall,  F.  M.,  M.D.,  New  York,  1891. 

Cohen  Solomon  Solis,  A.M.,  M.D.,  Philadel- 
phia, 1890,  1891, 

Cryer,  H.  M.,  M.D.,  Philadelphia.  1889. 

Deale,  Henry  B.,  M.D.,  Washington,  1891. 

Dolley,  C.  S.,  M.D.,   Philadelphia,  1889,  1890, 

Dollinger,  Julius.  M.D.,  Philadelphia,  1889. 
Borland,  W.  A.,  M.D.,  Philadelphia.  1891. 
Freeman,  Leonard,  M.D.,  Cincinnati,  1891. 
Goodell.  W.  Constantino,  M.D.,  Philadelphia, 

1888,  1889,  1890. 

Gould,  Geo.  M..M.D.,  Philadelphia,  1889,  1890. 
Greene,  E.  M..  M.D.,  Boston,  1891. 


1889. 

Hunt,  William,  M.D.,  Philadelphia,  1888,  1889. 
Jackson,  Henry,  M.D.,  Boston,  1891. 
Kirk,  Edward  C.,  D.D.S..  Philadelphia,  1888. 
Llovd,  James   Hendrie,   M.D.,  Philadelphia, 

'1888. 

McDonald,  Willis  G.,M.D.,  Albany,  1890. 
Penrose,  Chas.  B.,  M.D..  Philadelphia,  1890. 
Powell.  W.  M.,  M.D.,  Philadelphia,  1889,  1890, 

1891. 

Quimby,  Chas.  E.,  M.D.,  New  York,  1889. 
Sayre,  Reginald  H.,  M.D.,  New  York,  1890, 1891. 
Smith,    Allen  J.,  A.M.,  M.D.,    Philadelphia, 

1889,  1890. 

Vickery.  H.  F.,  M.D.,  Boston,  1891. 
Warneld.  Ridgely  B.,  M.D.,  Baltimore,  1891. 
Warner,  Frederick  M.,  M.D..  New  York.  1891. 
Weed.  Charles  L.,  A.M.,  M.D.,  Philadelphia, 

1888,  1889. 
Wells,  Brooks  H.,  M.D.,  New  York,  1888,  1889, 

1890,  1891. 

Wolff,  Lawrence,  M.D.,  Philadelphia,  1890. 
Wyman,  Walter,   A.M.,   M.D.,    Washington, 
1891. 

ASSISTANTS    TO    ASSOCIATE 
EDITORS. 

Baruch,  S.,  M.D.,  New  York,  1888. 
Beatty,  Franklin  T.,  M.D.,  Philadelphia,  1888. 
Brown,  Dillon,  M.D.,  New  York.  1888. 
Buechler,  A.  F.,  M.D.,  New  York,  1888. 
Burr,  Chas.  W.,  M.D..  Philadelphia,  1891. 
Cohen,   Solomon    Solis,    M.D.,    Philadelphia, 

1889. 

Cooke,  B.  G.,  M.D.,  New  York,  1888. 
Coolidge,  Algernon,  Jr.,  M.D.,  Boston,  1890. 
Currier,  A.  F.,  M.D.,  New  York,  1888. 
Daniels,  F.  H.,  A.M.,  M.D.,  New  York,  1888. 
Doale,  Henry  B..  M.D.,  Washington.  1890. 
Eshner,  A.  A.,  M.D.,  Philadelphia.  1891. 
Gould   George  M.,  M.D.,  Philadelphia,  1888. 
Grand;n,  Egbert  H.,  M.D.,  New  York,  1888, 

1889. 

Greene,  E.  M..  M  D..  Boston,  1890. 
Guite'ras,  G.  M.,  M.D..  Washington,  1890. 
Hance,  I.  H.,  A.M.,  M.D.,  New  York,  1891. 
Klrngenschmidt,  C.  H.  A.,  M.D.,  Washington, 

1890. 

Martin.  Edward,  M.D.,  Philadelphia,  1891. 
McKee,  E.  S.,  M.D.,  Cincinnati,  1889. 1890, 1891. 
Myers.  F.  H.,  M.D  .  New  York,  1888. 
Packard,  F.  A.,  M.D..  Philadelphia,  1890. 
Pritchard.  W.  B.,  M.D.,  New  York,  1891. 
Sangree,  E.  B.,  A.M..  M.D.,  Philadelphia,  1890. 
Soars,  G.  G.,  M.D.,  Boston,  J890. 
Shnlz,  R.  C.,  M.D..  New  York,  1891. 
Sou  were.  Geo.  F.,  M.D.,  Philadelphia.  1888. 
Taylor,  H.  L.,  M.D.,  Cincinnati,  1889,  1890. 
Vansant,  Eugene  L.,  M.D.,  Philadelphia,  1888. 


(28) 


Medical  Publications  of  The  F.  A,  Dams  Co.,  Philadelphia. 


ASSISTANTS    TO    ASSOCIATE 
EDITORS— (CONTINUED). 

Vickery,  H.  F.,  M.D.,  Boston,  1890. 

Warner,  F.  M.,  M.D.,  New  York,  1888,  1889, 

1890. 

Wells,  Brooks  H..  M.D.,  New  York,  1888. 
Wendt,  E.  C.,  M.D.,  New  York,  1888. 
Wilder,  W.  H.,  M.D.,  Cincinnati,  1889. 
Wilson,  C.  Meigs.  M.D.,   Philadelphia,  1889. 
Wilson,  W.  R.,  M.D.,  Philadelphia,  1891. 

CORRESPONDING    STAFF. 

EUROPE. 

Antal,  Dr.  Gesa  v., Puda-Pesth,  Hungary. 

Baginsky,  Dr.  A.,  Berlin,  Germany. 

Baratoux,  Dr.  J.,  Paris,  France. 

Barker,  Mr.  A.  E.  J .,  London,  England. 

Barnes,  Dr.  Fancourt,  London,  England. 

Bayer,  Dr.  Carl,  Prague,  Austria. 

Bouclmt,  Dr.  E.,  Pans,  France. 

Bourueville,  Dr.  A.,  Paris,  France. 

Bramwell,  Dr.  Byron,  Edinburgh,  Scotland. 

Carter,  Mr.  William,  Liverpool,  England. 

Caspari,  Dr.  G.  A.,  Moscow,  Russia. 

Chiralt  y  Selma,  Dr.  V.,  Seville,  Spain. 

Cordes,  Dr.  A.,  Geneva,  Switzerland. 

D'Estrees,  Dr.  Debout,  Contrexeville,  France. 

Diakonoff,  Dr.  P.  J.,  Moscow,  Russia. 

Dobrashian,  Dr.  G.  S.,  Constantinople,  Tur- 
key. 

Dole'ris,  Dr.  L.,  Paris,  France. 

Doutrelepont,  Prof.,  Bonn,  Germany. 

Doyon,  Dr.  H..  Lyons,  France. 

Drzewiecki,  Dr.  Jos.,  Warsaw,  Poland. 

Dubois-Reymond,  Prof.,  Berlin,  Germany. 

Ducrey,  Dr.  A.,  Naples,  Italy. 

Dujardin-Beaumetz,  Dr.,  Paris,  France. 

Duke,  Dr.  Alexander,  Dublin,  Ireland. 

Eklund,  Dr.  F.,  Stockholm,  Sweden. 

Fokker,  Dr.  A.  P.,  Groningen,  Holland. 

Fort,  Dr.  J.  A.,  Paris,  France. 

Fournier,  Dr.  Henri,  Paris,  France. 

Franks,  Dr.  Kendal,  Dublin,  Ireland. 

Fremy,  Dr.  H.,  Nice,  France. 

Fry,  Dr.  George,  Dublin,  Ireland 

Golowina,  Dr.  A,,  Varna,  Bulgaria. 

Gouguenheim,  Dr.  A.,  Paris,  France. 

Haig,  Dr.  A.,  London,  England. 

Hamon,  Mr.  A.,  Paris,  France. 

Harley,  Mr.  V.,  London,  England. 

Harley,  Mr.  H.  R.,  Nottingham,  England. 

Harley,  Prof.  Geo.,  London,  England. 

Harpe,  Dr.  de  la,  Lausanne,  Switzerland. 

Hartmann,  Prof.  Arthur,  Berlin,  Germany. 

Heitzmann,  Dr.  J.,  Vienna,  Austria. 

Helferich,  Prof.,  Greifswalrt,  Germany. 

Hewetson,  Dr.  Bendelack,  Leeds,  England. 

Hoff,  Dr.  E.  M.,  Copenhagen,  Denmark. 

Humphreys,  Dr.  F.  Rowland,  London,  Eng- 
land. 

IHingworth,  Dr.  C.  K.,  Accrington,  England. 

Jones,  Dr.  D.  M.  de  Silva,  Lisbon,  Portugal. 

Knott,  Dr.  J.  F.,  Dublin,  Ireland. 

Krause,  Dr.  H.,  Berlin,  Germany. 

Landolt,  Dr.  E.,  Paris,  France. 

Levison,  Dr.  J.,  Copenhagen,  Denmark. 

Lutaud,  Dr.  A.,  Paris,  France. 

Mackay,  Dr.  W.  A.,  Huelva,  Spain. 

Mackowen,  Dr.  T.  C.,  Capri,  Italy. 

Manche,  Dr.  L.,  Valetta,  Malta. 

Massei,  Prof.  F.,  Naples,  Italy. 

Mendez,  Prof.  R.,  Barcelona,  Spain. 

Meyer,  Dr.  E.,  Naples,  Italy. 

Meyer,  Prof.  W.,  Copenhagen.  Denmark. 

Monod,  Dr.  Charles.  Paris,  France. 

Montefusco,  Prof.  A.,  Naples,  Italy. 

More-Madden,  Prof.  Thomas,  Dublin,  Ireland. 

Morel,  Dr.  J.,  Ghent,  Belgium. 

Mygind,  Dr.  Holger,  Copenhagen,  Denmark. 

Mynlieff,  Dr.  A.,  Breukelen,  Holland. 

Napier,  Dr.  A.  D.  Leith,  London,  England. 

Nicolich,  Dr.,  Trieste,  Austria. 

Oberlander,  Dr.,  Dresden,  Germany. 

Obersteiner,  Prof.,  Vienna,  Austria. 

Pampoukis,  Dr.,  Athens,  Greece. 

Pansoni,  Dr.,  Naples,  Italy. 

Parker,  Mr.  Rushton,  Liverpool,  England. 

Pel,  Prof.  P.  K.,  Amsterdam,  Holland. 

Pippinskjold,  Dr.,  Helsingfors,  Finland. 

Pulido,  Prof.  Angel,  Madrid,  Spain. 


Rona,  Dr.  S.,  Buda-Pesth,  Hungary. 

Rosenbusch,  Dr.  L.,  Lvov.  Galicia. 

Rossbach,  Prof.  M.  F.,  Jena,  Germany. 

St.  Germain,  Dr.  de,  Paris,  France. 

Sanger,  Prof.  M.,  Leipzig,  Germany. 

Santa,  Dr.  P.  de  Pietra,  Paris,  France. 

Schiffers,  Prof.,  Liege,  Belgium. 

Schmiegelow,  Prof.  E.,  Copenhagen,  Den- 
mark. 

Scott,  Dr.  G.  M.,  Moscow.  Russia. 

Simon,  Dr.  Jules,  Paris,  France. 

Sollier,  Dr.  P.,  Paris,  France. 

Solowieff,  Dr.  A.  N.,  Lipetz,  Russia. 

Sota,  Prof.  R.  de  la,  Seville,  Spain. 

Sprimont,  Dr.,  Moscow,  Russia. 

Stockvis,  Prof.  B.  J.,  Amsterdam,  Holland. 

Szadek,  Dr.  Carl,  Kiew,  Russia. 

Tait,  Mr.  Lawson,  Birmingham,  England. 

Thiriar,  Dr..  Brussels,  Belgium. 

Triflletti,  Dr.,  Naples,  Italy. 

Tuke,  Dr.  D.  Hack,  London,  England. 

Ulrik,  Dr.  Axel,  Copenhagen,  Denmark. 

Unverricht,  Prof.,  Jena,  Germany. 

Van  der  Mey,  Prof.  G.  H.,  Amsterdam,  Hol- 
land. 


Van  Leent,  Dr.  F.,  Amsterdam,  Holland. 
Van  Millingen,  Prof.  E.,  Constantinople, 


key. 


Tur- 


Van  Rijnberk,  Dr.,  Amsterdam,  Holland. 
Wilson,  Dr.  George,  Leamington,  England. 
Wolfenden,  Dr.  Norris,  London,  England. 
Zweifel,  Prof.,  Leipzig,  Germany. 

AMERICA     AND     WEST     INDIES. 

Bittencourt,  Dr.  J.  C.,  Rio  Janeiro,  Brazil.  . 
Cooper,  Dr.  Austin  N.,  Buenos  Ayres,  Argen- 
tine Republic. 

Dagnino,  Prof.  Manuel,  Caracas,  Venezuela. 
Desvernine,  Dr.  C.  M..  Havana,  Cuba. 
Fernandez,  Dr.  J.  L.,  Havana,  Cuba. 
Finlay,  Dr.  Charles,  Havana,  Cuba. 
Fontecha,  Prof.  R.,  Tegucigalpa,  Honduras. 
Harvey,  Dr.  Eldon,  Hamilton,  Bermuda. 
Herdocia,  Dr.  E.  Leon,  Nicaragua. 
Levi,  Dr.  Joseph,  Colon,  U.  S.  Columbia. 
Mello.  Dr.  Vierra  de,  Rio  Janeiro,  Brazil. 
Moir,  Dr.  J.  W.,  Belize,  British  Honduras. 
Moncorvo,  Prof.,  Rio  Janeiro,  Brazil. 
Pla,  Dr.  E.  F..  Havana,  Cuba. 
Rake,  Dr.  Beaven,  Trinidad. 
Rincon,  Dr.  F.,  Maracaibo,  Venezuela. 
Semeleder,  Dr.  F.,  Mexico,  Mexico. 
Soriano,  Dr.  M.  S.,  Mexico,  Mexico. 
Strachan,  Dr.  Henry,  Kingston,  Jamaica. 

OCEANICA,     AFRICA,     AND    ASIA. 

— Baelz,  Prof.  R.,  Tokyo,  Japan. 
Barrett,  Dr.  Jas.  W.,  Melbourne,  Australia. 
Branfoot,  Dr.  A.  M.,  Madras,  India. 
Carageorgiades,  Dr.  J.  G.,  Lirnassol,  Cyprus. 
Cochran,  Dr.  Joseph  P.,  Oroomiah,  Persia. 
Celtman,  Dr.  Robert,  Jr.,  Che-foo,  China. 
Condict,  Dr.  Alice  W.,  Bombay,  India. 
Greece,  Dr.  John  M.,  Sydney,  Australia. 
Dalzell,  Dr.  J.,  Umsiga,  Natal. 
Diamantopulos,  Dr.  Geo.,  Smyrna,  Turkey. 
Drake-Brockman,  Dr.,  Madras,  India. 
Fitzgerald,  Mr.  T.  N.,  Melbourne,  Australia. 
Foreman,  Dr.  L.,  Sydney,  Australia. 
Gaidzagian.  Dr.  Ohan,  Adana,  Asia  Minor. 
Grant,  Dr.  David,  Melbourne,  Australia. 
Johnson,  Dr.  R.,  Dera  Isbmail  Khan,  Beloo- 

chistan. 

Kimura,  Prof.  J.  K.,  Tokyo,  Japan. 
Kiraggs,  Dr.  S.,  Sydney,  Australia. 
Manasseh,  Dr.  Beshara  I.,  Brummana,  Turkey 

in  Asia. 

McCandless,  Dr.  H.  H.  Hainan,  China. 
Moloney,  Dr.  J.,  Melbourne,  Australia. 
Neve,  Dr.  Arthur,  Bombay,  India. 
Perez,  Dr.  George  V.,  Puerto  Orotava,  Tene- 

riffe. 

Reid,  Dr.  John,  Melbourne,  Australia. 
Robertson,  Dr.  W.  S.,  Port  Said,  Egypt. 
Rouvier,  Prof.  Jules,  Beyrouth,  Syria. 
Scranton,  Dr.  William  B.,  Seoul,  Corea. 
Sinclair,  Dr.  H.,  Sydnev,  Australia. 
Thompson.  Dr.  James  B  ,  Petchaburee,  Siam. 
Wheeler,  Dr.  P.  d'E.,  Jerusalem,  Palestine. 
Whitney,  Dr.  H.  T.,  Foochow,  China. 
Whitney,  Dr.  W.  Norton,  Tokyo,  Japan. 


(29) 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 
RANNEY 

Lectures  on  Nervous  Diseases. 

FROM  THE  STAND-POINT  OF  CEREBRAL  AND   SPINAL  LOCALIZATION,  ANB 

THE  LATER  METHODS  EMPLOYED  IN  THE  DIAGNOSIS  AND 

TREATMENT  OF  THESE  AFFECTIONS. 

By  AMBROSE  L.  RANNEY,  A.M.,  M.D.,  Professor  of  the  Anatomy  and 
Physiology  of  the  Nervous  System  in  the  New  York  Post-Graduate 
Medical  School  and  Hospital ;  Professor  of  Nervous  and  Mental  Diseases 
in  the  Medical  Department  of  the  University  of  Vermont,  etc. ;  Author 
of  "  The  Applied  Anatomy  of  the  Nervous  System,"  "  Practical  Medical 
Anatomy,"  etc.,  etc. 

It  is  now  generally  conceded  that  the  nervous  system  controls  all 
of  the  physical  functions  to  a  greater  or  less  extent,  and  also  that  most 
of  the  symptoms  encountered  at  the  bedside  can  be  explained  and 
interpreted  from  the  stand-point  of  nervous  physiology. 

Profusely  illustrated  with  original  diagrams  and  sketches  in  color 
by  the  author,  carefully  selected  wood-engravings,  and  reproduced  photo- 
graphs of  typical  cases.  One  handsome  royal  octavo  volume  of  780  pages. 

SOLD  ONLY  BY  SUBSCRIPTION,  OB  SENT  DIRECT  ON  RECEIPT  OF  PRICE, 
SHIPPING  EXPENSES  PREPAID. 

Price,  in  United  States,  Cloth,  $5.50;  Sheep,  $6.50;  Half-Bussia,  $7.00. 
Canada'  (duty  paid),  Cloth,  $6.05 ;  Sheep,  $7.15  ;  Half- Russia,  $7.70. 
Great  Britain,  Cloth,  32s. ;  Sheep,  37s.  6d. ;  Half-Bussia,  40s.  France, 
Cloth,  34  fr.  70;  Sheep,  40  fr.  45;  Half-Russia,  43  fr.  30. 


We  are  glad  to  note  that  Dr.  Ranney  has 
published  in  book  form  his  admirable  lectures 
on  nervous  diseases.  His  book  contains  over 
seven  hundred  large  pages,  and  is  profusely 
illustrated  with  original  diagrams  and  sketches 
in  colors,  and  with  many  carefully  selected 
wood-cuts  and  reproduced  photographs  of 
typical  cases.  A  large  amount  of  valuable 
information,  not  a  little  of  which  has  but 
recently  appeared  in  medical  literature,  is  pre- 


sented in  compact  form,  and  thus  made  easily 
accessible.  In  our  opinion,  Dr.  Ranney's  book 
ought  to  meet  with  a  cordial  reception  at  the 
hands  of  the  medical  profession,  for,  ew;n 
though  the  author's  views  may  be  sometimes 
open  to  question,  it  cannot  be  disputed  that 
his  work  bears  evidence  of  scientific  method 
and  honest  opinion.— American  Journal  of 
Insanity. 


Practical  and  Scientific  Physiognomy; 


to 

By  MARY  OLMSTED  STANTON.  Copiously  illustrated.  Two  large 
Octavo  volumes. 

The  author,  MRS.  MARY  0.  STANTON,  has  given  over  twenty  years  to 
the  preparation  of  this  work.  Her  style  is  easy,  and,  by  her  happy 
method  of  illustration  of  every  point,  the  book  reads  like  a  novel  and 
memorizes  itself.  To  physicians  the  diagnostic  information  conveyed  is 
invaluable.  To  the  general  reader  each  page  opens  a  new  train  of  ideas. 
(This  book  has  no  reference  whatever  to  phrenology.  1 

SOLD  ONLY  BY  SUBSCRIPTION,  OR  SENT  DIRECT  ON  RECEIPT  OF  PRICE, 
SHIPPING  EXPENSES  PREPAID. 

Price,  in  United  States,  Cloth,  $9.00 ;  Sheep,  $11.00 ;  Half-Russia,  $13.00. 
Canada  (duty  paid),  Cloth,  $10.00;  Sheep,  $12.10;  Half-Russia, 
$14.30.  Great  Britain,  Cloth,  56s. ;  Sheep,  63s. ;  Half-Russia,  SOs. 
France,  Cloth,  30  fr.  30;  Sheep,  36  fr.  40;  Half-Russia,  43  fr.  30. 

(30) 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 


8  A  JO  US 

Lectures  on  the  Diseases  of  the  Nose 
and  Throat. 

DELIVERED  AT  THE  JEFFERSON  MEDICAL  COLLEGE,  PHILADELPHIA. 

By  CHARLES  E.  SAJOUS,  M.D. ,  Formerly  Lecturer  on  Rhinology  and 
Laryngology  in  Jefferson  Medical  College;  Chief  Editor  of  the  Annual  of  the 
Universal  Medical  Sciences,  etc.,  etc. 

B3P~  Since  the  publisher  brought  this  valuable  work  before  the  profession,  it 
hag  become  :  1st,  the  text-book  of  a  large  number  of  colleges  ;  3d,  the  reference-book 
of  the  U.  8.  Army,  Navy,  and  the  Marine  Service;  and,  3d,  an  important  and 
valued  addition  to  the  libraries  of  over  12,000  physicians. 

This  book  has  not  only  the  inherent  merit  of  presenting  a  clear  expose  of 
the  subject,  but  it  is  written  with  a  view  to  enable  the  general  practitioner  to 
treat  his  cases  himself.  To  facilitate  diagnosis,  colored  plates  are  introduced, 
showing  the  appearance  of  the  different  parts  in  the  diseased  state  as  they  appear 
in  nature  by  artificial  light.  No  error  can  thus  be  made,  as  each  affection  of  the 
nose  and  throat  has  its  representative  in  the  100  chromo-lithographs  presented.  In 
the  matter  of  treatment,  the  indications  are  so  complete  that  even  the  slightest 
procedures,  folding  of  cotton  for  the  forceps,  the  use  of  the  probe,  etc.,  are 
clearly  explained. 

Illustrated  with  100  chromo-lithographs,  from  oil  paintings  by  the  author, 
and  93  engravings  on  wood.  One  handsome  royal  octavo  volume. 

SOLD  ONLY  BY  SUBSCRIPTION,  OR  SENT  DIRECT  ON  RECEIPT  OF  PRICE, 
SHIPPING  EXPENSES  PREPAID. 

Price,  in  United  States,  Cloth,  Boyal  Octavo,  $4.00;  Ealf-Bussia,  Royal 
Octavo,  $5.00.  Canada  (duty  paid),  Cloth,  $110;  Half-Bussia,  $5.50. 
Groat  Britain,  Cloth,  22s.  6d. ;  Sheep  or  Half-Bussia,  28s.  France, 
Cloth,  21  fr.  60 ;  Half-Bussia,  30  fr.  30. 


It  is  intended  to  furnish  the  general  practi- 
tioner not  only  with  a  guide  for  the  treatment 
of  diseases  of  the  nose  and  throat,  but  also  to 
place  before  him  a  representation  of  the  nor- 
mal and  diseased  parts  as  they  would  appear 


to  him  were  they  seen  in  the  living  subject. 
As  a  guide  to  the  treatment  of  the  nose  and 
throat,  we  can  cordially  recommend  this  work. 
— Boston  Medical  and  Surgical  Journal. 


IMPORTANT  ANNOUNCEMENT.      IN  PREPARATION. 


PSYCHOPATHIA    SEXUALIS :    With   Especial   Reference  to  Contrary 
Sexual  Instinct. 

By  DR.  R.  VON  KRAFFT-EBING,  Professor  of  Psychiatry  and  Neurology 
in  the  University  of  Vienna.  Authorized  translation  of  the  Seventh  German 
Edition  by  CHARLES  GILBERT  CHADDOCK,  M.D  ,  Assistant  Medical  Superin- 
tendent Northern  Michigan  Asylum  ;  Fellow  of  the  Chicago  Academy  of 
Medicine. 

Prof,  von  Krafft-Ebing's  study  of  the  Psychopathology  of  the  sexual  life 
was,  when  first  published,  a  small  monograph;  but  in  the  seven  editions 
through  which  it  has  passed  so  rapidly  it  has  received  so  many  additions  and 
been  made  to  cover  so  completely  every  aspect  of  the  anomalies  of  the  sexual 
sphere  that  the  work  now  deserves  the  name  of  a  treatise.  It  easily  supersedes 
all  previous  attempts  to  treat  this  important  subject  scientifically,  and  it  is 
sure  to  commend  itself  to  members  of  the  medical  and  legal  professions  as  a 
scientific  explanation  of  many  social  and  criminal  enigmas  to  which  no  work 
in  English  offers  a  solution. 

The  work  will  be  sold  only  by  Subscription  to  Members  of  the  Medical  and 
Legal  Professions. 

(31) 


Medical  Publications  of  The  F.  A.  Davis  Co.,  Philadelphia. 

In  Press  and  in  Preparation. 


AUTO-INTOXICATION  :  Self- Poisoning  of  the  Individual. 

Being  a  series  of  lectures  on  Intestinal  and  Urinary  Pathology.  By  Prof. 
BOUCHARD,  Paris.  Translated  from  the  French  with  an  Original  Appendix. 
By  THOMAS  OLIVER,  M.D.,  Professor  of  Physiology,  University  of  Durham, 
England.  In  one  12mo  volume.  IN  PRESS. 

DISEASES  OF  THE  LUNGS,  HEART,  AND  KIDNEYS. 

By  N.  S.  DAVIS,  JR.,  A.M.,  M.D.,  Professor  of  Principles  and  Practice  of 
Medicine,  Chicago  Medical  College;  Physician  to  Mercy  Hospital,  Chicago  ; 
Member  of  the  American  Medical  Association,  etc.,  etc.  In  one  neat  12ino 
volume.  No.  in  the  Physicians'  and  Students'  Ready -Reference  Series. 
IN  PRESS. 

TUBERCULOSIS  OF  THE  BONES  AND  JOINTS. 

By  N".  SENN,  M.D.,  Ph.D.,  Professor  of  Practice  of  Surgery  and  Clinical 
Surgery  in  Rush  Medical  College,  Chicago,  111.;  Professor  of  Surgery  in  the 
Chicago  Polyclinic  ;  Attending  Surgeon  to  the  Milwaukee  Hospital ;  Con- 
sulting Surgeon  to  the  Milwaukee  County  Hospital  and  to  the  Milwaukee 
County  Insane  Asylum  ;  author  of  a  text-book  on  the  "Principles  of  Surgery," 
etc.,  etc.  In  one  handsome  Royal  Octavo  volume.  Illustrated  with  upwards 
of  one  hundred  (100)  engravings.  IN  PRESS. 

A  PRACTICE  OF  SURGERY. 

By  JOHN  H.  PACKARD,  A.M.,  M.D  ,  Surgeon  to  the  Pennsylvania  Hospital 
and  to  St.  Joseph's  Hospital,  Philadelphia  ;  Member  of  the  American  Surgical 
Association  and  of  the  American  Medical  Association  ;  formerly  Acting 
Assistant  Surgeon  U.  S.  Army  (1861-65),  etc.,  etc.  In  one  large  Roj'al 
Octavo  volume.  Handsomely  illustrated.  IN  PREPARATION. 

PRACTICAL  GYN/ECOLOGY. 

By  E.  E.  MONTGOMERY,  A.M.,  M.D.,  Professor  of  Clinical  Gynaecology 
in  the  Jefferson  Medical  College,  Philadelphia ;  Obstetrician  to  the  Phila- 
delphia Hospital ;  Gynaecologist  to  the  St.  Joseph  Hospital ;  Fellow  and 
ex-President  of  the  American  Association  of  Obstetricians  and  Gynaecologists, 
etc.,  etc.  In  one  handsome  Royal  Octavo  volume.  Thoroughly  and  beauti- 
fully illustrated.  IN  PREPARATION. 

CHILDBED:  ITS  MANAGEMENT;  DISEASES  AND  THEIR  TREAT- 
MENT. 

By  WALTER  P.  MANTON,  M.D.,  Visiting  Physician  to  the  Detroit  'Woman's 
Hospital ;  Consulting  Gynaecologist  to  the  Eastern  Michigan  Asylum  ;  Presi- 
dent of  the  Detroit  Gynaecological  Society  ;  Fellow  of  the  American  Society 
of  Obstetricians  and  Gynaecologists  and  of  the  British  Gynaecological  Society; 
Member  of  Michigan  State  Medical  Society,  etc.  In  one  neat  12rno  volume. 
IN  PREPARATION. 

SYPHILIS  IN  THE  MIDDLE  AGES  and  SYPHILIS  IN  MODERN  TIMES. 

Being  Volumes  II  and  III  of  a  treatise  on  "Syphilis  To-Day  and  Among 
the  Ancients."  By  Dr.  F.  BURET,  of  Paris.  Translated  from  the  French 
with  notes,  by  A.  H.  OHMANN-DUMESNIL,  M.D.,  Professor  of  Dermatology 
and  Syphilology  in  the  St.  Louis  College  of  Physicians  and  Surgeons ;  Con- 
sulting Dermatologist  to  the  St.  Louis  City  Hospital;  Physician  for  Cutaneous 
Diseases  to  the  Alexian  Brothers'  Hospital,  etc.,  etc.  Each  volume  12mo, 
Cloth.  To  be  issued  in  the  Physicians'  and  Students'  Ready-Reference 
Series.  IN  PREPARATION. 

(32) 


University  of  California 

SOUTHERN  REGIONAL  LIBRARY  FACILITY 

Return  this  material  to  the  library 

from  which  it  was  borrowed. 


A 


A  000  507  907  4 


WE253 
SU78t 
1892 

Senn,  Nicholas 

Tuberculosis  of  "bones  and 

joints 


WE253 
SklQt 
1892 
Senn,  Nicholas 

Tuberculosis  of  bones  and  joints 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

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